CENTER AT PARK WEST, LLC, THE

A recertification survey with complaint #CO2671583, #CO2717869, #CO2789038, #CO2995596, #CO3018740 and #CO3050251 was completed on 6/22/26 to 6/25/26. Five deficiencies were cited.

An Emergency Preparedness survey was conducted from 6/22/26 to 6/25/26. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for one (#81) of three residents reviewed for grievances out of 37 sample residents. Specifically, the facility failed to ensure Resident #81’s grievance concerning late administration of as-needed (PRN) pain medication was documented, investigated, and resolved. Findings include:I. Facility policy and procedure The Grievances policy and procedure, revised 1/8/24, was provided by the nursing home administrator (NHA) on 6/24/26 at 4:56 p.m. It read in pertinent part, “The purpose of this policy is to ensure all patients, legal representatives/responsible parties, staff, and visitors are aware of the facility’s grievance procedure.“Each resident, resident’s representative and his or her responsible parties, family members, staff, and visitors have the right to voice complaints and/or grievances without discrimination or the fear of reprisal. Such grievances include those regarding care, treatment, or other matters related to the quality of care or quality of life.“Grievances can be communicated to a staff member either verbally or in writing.“The facility would make every effort to promptly investigate and resolve any grievances.”II. Resident #81A. Resident status Resident #81, age greater than 65, was admitted on 4/15/26. According to the June 2026 computerized physician orders (CPO), diagnoses included sepsis due to methicillin susceptible staphylococcus aureus (a severe life threatening medical emergency that occurs when a localized infection caused by a specific strain of bacteria enters the bloodstream and triggers a violent, body wide immune response, type 2 diabetes mellitus, metabolic encephalopathy (a temporary or permanent brain dysfunction caused by a chemical imbalance in the body) and muscle weakness. The 4/22/26 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He was dependent with toileting and transfers, required supervision or touch assistance with personal hygiene and was independent with eating. B. Resident interviewResident #81 was interviewed on 6/23/26 at approximately 12:00 p.m. Resident #81 said he had waited over four hours to receive his requested PRN pain medication a few days ago. Resident #81 said he was deeply unhappy with the situation because he was in constant pain and did not receive his medication when it was needed. Resident #81 said he reported the incident to the facility case manager the following morning, but he had not received any feedback regarding his concern. According to Resident #81, the case manager told him he was not the only resident she had heard express concerns about late medications that morning. Resident #81 said that no formal grievance form was completed at the time of the initial report or during the subsequent days. Resident #81 said that due to the delay in receiving his PRN medication, his pain increased from a pain level of 5 to a pain level of 7 on a pain scale of 1-10. C. Record reviewA review of Resident #81’s June 2026 CPO revealed the following physician’s orders for PRN pain medications:Ibuprofen oral tablet 400 milligrams (mg). Give one tablet by mouth every six hours for pain, ordered4/29/26 and discontinued 6/1/26. Ibuprofen oral tablet 600 mg by mouth every six hours as needed for pain and comfort with, ordered 6/1/26. Oxycodone HCI oral tablet 15 mg. Give 15 mg orally every six hours PRN for pain level 1 to 10; give 10 mg for pain level 1 to 6; give 15 mg for pain level 7 to 10, ordered 4/15/26. Review of Resident #81’s pain management care plan, initiated 4/15/26, revealed the resident had acute and chronic pain related to infection, type two diabetes mellitus, deep vein thrombosis, and muscle spasm. Interventions included actively listening to Resident #81’s concerns as needed; administering pain medications according to physician’s orders and monitoring for effectiveness.-A review of the facility’s Grievance Log, from 1/1/26 through 6/24/26, revealed that no entry had been documented regarding Resident #81’s reported concern about his late PRN pain medication. III. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 6/24/26 at 3:51 p.m. LPN #3 said Resident #81 had chronic pain and his PRN pain medications should be given on time when requested. LPN #3 said the grievances were followed for any concerns expressed by a resident orally or in writing. LPN #3 said that, as the unit manager, she documented all concerns brought to her attention and followed up on them. LPN #3 said she was not aware of any delay in receiving pain medications for Resident #81. The case manager was interviewed on 6/25/26 at 9:45 a.m. The case manager said the facility’s grievance process was that when a resident had a concern, the resident was encouraged to report the concern to any staff member, and staff ensured that the social services consultant was informed. The case manager said the department manager, who was responsible for the department, would handle the grievance to ensure a resolution was reached. The case manager said Resident #81 informed her of his concerns about not receiving his PRN pain medication timely when requested. The case manager said she did not remember the exact date the resident reported the incident to her. The case manager said she did not complete a grievance form and did not inform the unit manager of the incident. The NHA was interviewed on 6/25/26 at 10:15 a.m. The NHA said staff members filled out the grievance forms whenever a resident reported concerns with their stay at the facility. The NHA said concerns about care needed to be addressed immediately by the department heads. The NHA said he would then review the grievance forms to ensure the resolution was reached to the resident’s satisfaction. The NHA said the case manager should have reported and documented Resident #81’s concerns regarding the resident’s delay in receiving his PRN medication when it was requested. He said he did not understand why the case manager failed to document and follow up on the resident’s pain concerns. The NHA said he would immediately provide education on the grievance process to all the facility staff members.

Based on observations, record review and interviews, the facility failed to ensure respiratory care was provided in accordance with professional standards for four (#84, #81, #88 and #49) of eight residents out of 37 sample residents. Specifically, the facility failed to:-Ensure a physician’s order was obtained for the use, setting, and required cleaning of Resident #84 and Resident #81’s CPAP (continuous positive airway pressure) machines;-Ensure Resident #88’s oxygen was administered according to the physician’s orders; and,-Ensure Resident #49’s nebulizer (medical device that converts liquid medication into a fine mist) equipment was cleaned and maintained appropriately. Findings include:I. Failed to ensure a physician’s order was obtained for the use, setting, and required cleaning of Resident #84 and Resident #81’s CPAP machines A. Facility policy and procedureThe Bi-level Positive Airway Pressure (BiPAP)/Continuous Positive Airway Pressure (CPAP) policy, revised 2/8/21, was provided by the nursing home administrator (NHA) on 6/24/26 at 4:51 p.m. It revealed in pertinent part, "The resident will receive necessary respiratory care and services in accordance with professional standards of practice, resident’s care plan, and the resident’s choice."Residents will have orders that include settings for CPAP/BiPAP. "CPAP/BiPAP will be cleaned per manufacturer’s guidelines."B. Resident #841. Resident statusResident #84, age less than 65, was admitted on 6/19/26. According to the June 2026 computerized physician orders (CPO), diagnoses included asthma, chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure. The 6/25/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The MDS assessment revealed that the resident required a CPAP machine and continuous oxygen. 2. ObservationsOn 6/22/26 at 2.16 p.m. Resident #84 was sitting on her bed with her oxygen on via nasal cannula. There was a CPAP machine on a sofa with the mask and tubing connected to the CPAP. There was no storage bag. On 6/23/26 at 9:15 a.m. Resident #84 was lying in bed with her CPAP mask over her nose. Resident #84’s CPAP machine was in the same spot on the sofa. The humidifier chamber was connected to the resident’s CPAP machine; there was an unmeasurable amount of water in the chamber, and condensation was visible on the walls of the chamber. On 6/24/26 at 4:33 p.m. Resident #84 was asleep in bed. She was not wearing her CPAP mask. She was wearing a nasal cannula and receiving oxygen via the oxygen wall unit. The humidifier chamber of the CPAP machine had a minimal amount of water in it. Condensation was visible on the walls of the humidifier chamber. 3. Resident interviewResident #84 was interviewed on 6/24/26 at 2:35 p.m. Resident #84 said she wore her CPAP every night. Resident #84 said the facility staff had not cleaned her CPAP machine since her admission to the facility (on 6/19/26). Resident #84 said her CPAP machine and mask had been left on the sofa without protective covers. 4. Record reviewA review of Resident #84’s respiratory care plan, initiated 6/19/26, revealed the resident had respiratory risks related to deficiencies/abnormalities in pulmonary function, including COPD, asthma, chronic respiratory failure, and sleep apnea. Interventions included administering and providing respiratory therapy and respiratory treatment interventions per the physician’s order and the use of a CPAP per physician’s orders.-The care plan failed to include documentation for settings, cleaning instructions and cleaning frequency for the CPAP machine.-Review of Resident #84’s June 2026 CPO did not reveal physician’s orders for the CPAP settings or maintenance of the CPAP machine. Review of Resident #84’s June 2026 medication administration record/treatment administration records (MAR/TAR) did not reveal documentation that cleaning was beingcompleted for the resident’s CPAP machine. C. Resident #811. Resident status Resident #81, age greater than 65, was admitted on 4/15/26. According to the June 2026 CPO, diagnoses included sepsis due to methicillin susceptible staphylococcus aureus (a severe life threatening medical emergency that occurs when a localized infection caused by a specific strain of bacteria enters the bloodstream and triggers a violent, body wide immune response, type 2 diabetes mellitus, metabolic encephalopathy (a temporary or permanent brain dysfunction caused by a chemical imbalance in the body) and muscle weakness. The 4/22/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The MDS assessment indicated the resident utilized a BiPAP.2. ObservationsOn 6/22/26 at 1:14 p.m. Resident #81 was sitting in his room in his wheelchair with his oxygen on via nasal cannula. There was a CPAP machine on a sofa with the mask and tubing connected to the CPAP. There was no protective bag covering the mask. The face of the mask was directly resting on the sofa. The humidifier chamber contained an unmeasurable amount of water, and condensation was visible on the sides and top of the chamber. On 6/23/26 at 11:55 a.m. Resident #81 was sitting in his wheelchair in his room. The CPAP machine was still on the sofa by his bed, with the mask and tubing connected to it. There was no protective bag covering the mask. The humidifier chamber contained an unmeasurable amount of water, and condensation was visible on the sides and top of the chamber. 3. Resident interviewResident #81 was interviewed on 6/23/26 at approximately 12:10 p.m. Resident #81 said he had been using his CPAP machine since he was admitted to the facility (on 4/15/26). Resident #81 said the CPAP machine had not been cleaned since his admission to the facility. Resident #81 said the CPAP machine had been stored on the bedside sofa with the mask and tubing. Resident #81 said he had not seen the mask and tubing stored in a protective cover. 4. Record reviewA review of Resident #81’s June 2026 CPO revealed the following physician’s orders:Initiate CPAP at bedtime. Enter settings 4.0 cm (centimeters). No oxygen required for this order, ordered 4/16/26. CPAP cleaning instructions: Hand-wash mask/headgear (may be washed without being disassembled) using warm water and mild soap. Rinse well with quality drinking water. Allow to air dry out of direct sunlight, ordered 6/23/26.-However, Resident #81's CPAP use had been initiated on 4/16/26, but the CPAP cleaning order was not initiated until 6/23/26 (during the survey). A review of Resident #81’s respiratory care plan, initiated 4/15/26, revealed that the resident had respiratory risks related to deficiencies/abnormalities in pulmonary function. Interventions included administering and providing respiratory therapy and respiratory treatment interventions per the physician’s order and the use of a CPAP per physician’s orders.-However, the care plan failed to establish or include any specific protocols, frequencies, or staff responsibilities regarding the cleaning, sanitization, and maintenance of the CPAP equipment. D. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 6/24/26 at 3:34 p.m. LPN #2 said he did not usually work on the unit and was not sure what Resident #84 and Resident #81’s CPAP orders were. LPN #2 looked at Resident #84’s June 2026 CPO and said there was no physician’s order for the resident’s CPAP use, settings, cleaning, and maintenance of the device. LPN #2 said Resident #81 had a physician’s order for CPAP use; however, she did not see a physician’s order for device cleaning or maintenance. LPN #2 said there should be a physician’s order for the settings and cleaning of the CPAP machine to prevent possible respiratory infections. LPN #3 was interviewed on 6/24/26 at 3:45 p.m. LPN #3 said she was the unit manager. LPN #3 said all CPAP machines required a physician’s order for the use, settings, and maintenance of each device. LPN #3 said during the admission process, the admitting nurse should ensure that the admitting physician’s orders included the use of any medical devices the residents were admitted with. LPN #3 said it was important to ensure physician’s orders were in place for each medical device to ensure proper use and maintenance of the equipment. The nurse practitioner (NP) was interviewed on 6/24/26 at 4:22 p.m. The NP said all CPAP machines should have an active physician’s order, including an order for cleaning and maintenance of the device. The director of nursing (DON) and the regional director of clinical services were interviewed together on 6/24/26 at 5:09 p.m. The DON said the facility had independently identified an opportunity for improvement during a mock survey conducted on 6/11/26. He said following that review, the issue regarding physician’s orders and respiratory equipment cleaning concern was immediately entered into the quality assurance performance improvement (QAPI) program, and a formal Plan of Correction was initiated on 6/11/26. The DON said all nursing staff were trained to ensure respiratory compliance. The DON said he did not know why the staff failed to ensure compliance with the physician's orders for Resident #81. The DON said he would immediately provide re-education to the nursing staff. The DON said he could not explain the reason the plan of correction for their mock survey did not prevent Resident #84’s CPAP failures. II. Failed to ensure Resident #88’s oxygen was administered according to the physician’s orders A. Facility policy and procedureThe Oxygen Administration policy, revised 8/3/23, was provided by the NHA on 6/24/26 at 4:51 p.m. It revealed in pertinent part, "For a resident receiving oxygen therapy, the resident’s record must reflect ongoing evaluation of the resident’s respiratory status, response to oxygen therapy and include, at a minimum, the attending practitioner’s orders." The ResMed CPAP Cleaning Manufacturer Guidelines, undated, was provided by the NHA on 6/24/26 at 4:51 p.m. It revealed in pertinent part, "Hand wash mask/headgear (may be washed without being disassembled) using warm water and mild soap. Rinse well with drinking-quality water. Allow to air dry out of direct sunlight.“Flex fit CPAP cleaning instructions: Hand-wash the headgear in pure soap dissolved in lukewarm water. Do not soak for longer than ten minutes, then rinse in fresh water and allow to dry out of direct sunlight. It is not necessary to remove the clip from the headgear when washing. Only have to clean every seven days.“Respironics CPAP cleaning instructions: Hand-wash the mask in warm water with mild liquid soap, ensuring all visible dirt is removed. Rinse thoroughly with warm water to remove soap. Allow the mask to air dry out of direct sunlight.“Astral- Hand wash mask/headgear (may be washed without being disassembled) using warm water and mild soap. Rinse well with drinking-quality water. Allow to air dry out of direct sunlight." B. Resident #881. Resident statusResident #88, age greater than 65, was admitted on 6/19/26. According to the June 2026 CPO, diagnoses included COPD and dependence on supplementary oxygen. The 6/25/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The MDS assessment indicated Resident #88 received oxygen therapy. 2. ObservationsOn 6/22/26 at 2:23 p.m. Resident #88 was lying on his bed in his room. He was wearing a nasal cannula connected to an oxygen wall outlet, set to 2.5 liters per minute (LPM) of oxygen. On 6/23/26 at 9:05 a.m. Resident #88 was lying in bed with his oxygen wall outlet set to 2.5 LPM.On 6/24/26 at 10:07 a.m. Resident #88 moved to a different room. Resident #88 was observed in bed in the new room with his nasal cannula on and the oxygen flow rate on the oxygen wall outlet was set at 2.5 LPM. -However, the resident’s physician's order for oxygen specified an oxygen flow rate of 1 LPM (see record review below). 3. Resident interviewResident #88 was interviewed on 6/24/26 at 11:14 a.m. Resident #88 said he did not know what liter flow he was receiving for his oxygen use. Resident #88 said he was unable to reach the wall outlet to tamper with his oxygen. Resident #88 said the facility staff managed the liter flow of her oxygen. 4. Record reviewReview of Resident #88’s June 2026 CPO revealed the following physician’s orders:Oxygen to be on at 1 LPM (continuously), delivered through a nasal cannula. May titrate if oxygen drops below 88% (oxygen saturation level), increasing by 0.5LPM every five minutes until oxygen is 88% to 94%. Re-evaluate in 24 hours and titrate back down by 0.5 LPM every five minutes until oxygen is between 88% and 90%. If the resident has COPD and oxygen dropped below 85%, may titrate by 0.5 LPM every five minutes until oxygen is 85% to92%. Re-evaluate in 24 hours and bring back down by 0.5 LPM until oxygen is 85% to 90% every shift and as needed.-However, observations revealed the resident’s oxygen flow rate was set to 2.5 LPM (see observations above). The oxygen therapy care plan, initiated 6/19/26, documented that Resident #88 had respiratory risk related to respiratory deficiencies and abnormalities in pulmonary function. Interventions included administering oxygen as ordered, monitoring breath sounds as needed, and monitoring for shortness of breath.-The care plan did not include the physician’s orders for oxygen flow rate and oxygen titration. Review of Resident #88’s vital signs documentation from 6/19/26 to 6/24/26 revealed the following: -On 6/19/26 at 6:00 p.m. Resident #88’s oxygen saturation level was 98% on 1 LPM;-On 6/19/26 at 7:10 p.m. Resident #88’s oxygen saturation level was 95% on room air;-On 6/20/26 at 7:01 a.m. Resident #88’s oxygen saturation level was 96% on room air;-On 6/20/26 at 4:20 p.m. Resident #88’s oxygen saturation level was 96% on room air;-On 6/20/26 at 8:23 p.m. Resident #88’s oxygen saturation level was 96% on room air;-On 6/21/26 at 8:00 a.m. Resident #88’s oxygen saturation level was 92% but the LPM was not documented;.-On 6/21/26 at 9:11 p.m. Resident #88’s oxygen saturation level was 98% but the LPM was not documented;-On 6/22/26 at 6:44 a.m. Resident #88’s oxygen saturation level was 92% but the LPM was not documented;-On 6/22/26 at 8:24 p.m. Resident #88’s oxygen saturation level was99% but the LPM was not documented;-On 6/23/26 at 7:02 a.m. Resident #88’s oxygen saturation level was 96% but the LPM was not documented;-On 6/23/26 at 7:33 p.m. Resident #88’s oxygen saturation level was 92% but the LPM was not documented;-On 6/24/26 at 8:00 a.m. Resident #88’s oxygen saturation level was 100% but the LPM was not documented.-However, there was no documentation indicating the resident needed more oxygen, based on the documented oxygen saturations (see observations above). C. Staff interviewsRegistered nurse (RN) #1 was interviewed on 6/24/26 at 3:41 p.m. RN #1 observed Resident #88’s oxygen wall outlet flow rate setting and acknowledged the resident’s oxygen flow rate was set at 2.5 LPM. RN #1 said she was not aware of any medical necessity that would require increased oxygenation or any new oxygen orders in Resident #88’s electronic medical record (EMR). After RN #1 reviewed the physician’s order for Resident #88’s oxygen, she confirmed the oxygen flow rate was supposed to be set at 1 LPM. RN #1 said she would normally check a resident's oxygen flow rate setting and their oxygen saturation level during her shift, and if there was a discrepancy noted, she would investigate the reason the oxygen flow rate was different from what the physician’s order indicated and adjust it if needed. She said nurses should not document the incorrect oxygen flow rate on the EMR.The NP was interviewed on 6/24/26 at 4:22 p.m. The NP said prescribed oxygen was a medication, not a comfort measure. The NP said changing the oxygen flow rate for a resident outside of a physician’s order could have adverse consequences for a resident with COPD. The NP said it was critical that the clinical staff thoroughly documented any medical necessity that required additional or less oxygen and immediately notified the provider. The NP said the residents’ care plans should be updated to include interventions for staff to follow. The director of nursing (DON) and the regional director of clinical services were interviewed together on 6/24/26 at 5:09 p.m. The DON said the nursing staff were expected to document any changes in oxygen flow rate and the rationale for the change in the residents’ EMR.The regional director of clinical services said oxygen was part of the residents' medications and that all physician’s oxygen orders needed to be followed. The regional director of clinical services said that failure to follow the physician’s order for oxygenation could result in health complications, such as respiratory failure, depending on each resident's condition.

Based on observations, record review and interviews, the facility failed to ensure two (#18 and #36) of three residents reviewed for medication administration out of 37 sample residents were kept free from significant medication errors. Specifically the facility failed to:-Ensure the insulin pen was primed prior to an insulin medication administration for Resident #18; and,-Ensure pain medications documented on Resident #36’s allergy list were not ordered and available for administration to the resident. Findings include:I. Failed to ensure the insulin pen was primed prior to insulin administration for Resident #18A. Professional referenceAccording to the manufacturer Eli Lilly and Company, Instructions for Use, Insulin Lispro Kwik Pen, July 2023, retrieved on 6/29/26 from https://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf, “Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. “To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle pointing up. Push the dose knob in until it stops and “0” is seen in the dose window. Hold the dose knob and count to five slowly. You should see insulin at the tip of the needle.”B. Facility policy and procedureThe Insulin Pen Injections policy, revised 6/14/22, was provided by the director of nursing (DON) on 6/24/26 at 11:45 a.m. It read in pertinent part, “Remove the cap of the insulin pen. If the insulin in the pen appears cloudy, roll the pen in your hands and turn it from side to side until mixed. You do not have to roll the pen if the insulin is completely clear. Wipe the rubber stopper with an alcohol wipe. Attach a new pen needle onto the insulin pen. Prime the insulin pen. Priming means removing air bubbles from the needle, and ensures that the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the dosage knob to the two units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears.”C. Resident #181. Resident statusResident #18, age greater than 65, was admitted on 6/10/26. According to the June 2026 computerized physician orders (CPO), diagnoses included displaced fracture of right humerus (upper arm), diabetes, kidney disease and atrial fibrillation (an irregular, rapid heart rate). The 6/16/26 minimum data set (MDS) assessment identified Resident #18 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The MDS assessment revealed the resident was independent with eating, required substantial assistance with personal hygiene, toileting, showering and transferring. 2. ObservationOn 6/24/26 at 10:20 a.m. registered nurse (RN) #2 was in Resident #18’s room preparing to administer insulin Lispro to the resident. RN #2 cleaned the tip of the insulin Lispro pen with an alcohol pad, applied a new needle and then dialed the insulin pen to four units. RN #2 showed Resident #18 the pen dialed to four units, cleaned the resident’s abdomen on the left side with an alcohol swab, removed the safety cap and administered the injected medication. -RN #2 failed to prime the resident’s insulin pen per manufacturer's directions (see professional reference above) prior to administering the medication to the resident. 3. Record reviewReview of Resident #18’s June 2026 CPO revealed the following physician’s order:Insulin Lispro solution pen-injector 100 units per milliliter (ml). Inject four units subcutaneously (SQ) three times a day, ordered 6/24/26. D. Staff interviewsRN #2 was interviewed on 6/24/26 at 10:24 a.m. RN #2 said she did not prime the insulin pen prior to administering insulin to Resident #18. RN #2 said she was an agency nurse and some of the nursing facilities she worked at primed insulin pens, and others did not. RN #2 said she did not know if she needed to prime the insulin pen at this facility. RN #2 said she did not know if Resident #18 received all of the insulin dose that was ordered. The DON was interviewed on 6/24/26 at 10:37 a.m. The DON said all insulin pens should be primed prior to the administration of insulin. The DON said RN #2 should have primed the insulin pen to ensure the entire dose of insulin was administered to Resident #18. II. Failed to ensure pain medications documented on Resident #36’s allergy list were not ordered and available for administration to the residentA. Facility policy and procedureThe Allergy Identification and Management policy, initiated 1/1/24, was provided by the nursing home administrator (NHA) on 6/25/26 at 3:30 p.m. It read in pertinent part, “Patient allergy and adverse reaction information should be obtained, documented, and communicated as part of the assessment and care process.“Allergy information may be reviewed and updated as new information becomes available or when clinically appropriate.“Allergy information should be available in the medical record to support safe care and medication administration.“Review allergy information during medication reconciliation and before administering medications or treatments, as appropriate.”B. Resident #361. Resident statusResident #36, age greater than 65, was admitted on 3/12/26. According to the June 2026 CPO, diagnoses included compression fractures of vertebrae (spine), respiratory failure, heart disease and dementia. The 5/4/26 MDS assessment identified Resident #36 was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident required set- up assistance with eating, moderate assistance with dressing and substantial assistance with toileting, showering and transferring. 2. Resident interviewResident #36 was interviewed on 6/22/26 at 2:35 p.m. Resident #36 said earlier that day (6/22/26), the nurse offered to give her oxycodone for her pain. Resident #36 said she told the nurse she could not take the oxycodone medication because she was allergic to it. Resident #36 said oxycodone made her very sick in the past and she could not tolerate it. Resident #36 said she could take hydrocodone, but not oxycodone. 3. Record reviewA review of Resident #36’s electronic medical record (EMR) on 6/22/26 at 2:45 p.m. revealed she had allergies to oxycodone, Percocet (oxycodone combined with acetaminophen), and Vicodin (hydrocodone combined with acetaminophen). Review of Resident #36’s June 2026 CPO revealed the following physician’s orders:Hydrocodone-acetaminophen oral tablet, 5-325 milligrams (mg). Give one tablet by mouth every four hours as needed for moderate pain, ordered 5/5/26. Hydrocodone-acetaminophen oral tablet, 5-325 mg. Give two tablets by mouth every four hours as needed for severe pain, ordered 5/5/26. Oxycodone hydrochloride (HCL) tablet 5 mg. Give one tablet by mouth every four hours as needed for pain, one to 10 out of 10 (rating of pain), ordered 6/16/26 and discontinued 6/22/26 at 5:56 p.m. (during the survey)Review of Resident #36’s June 2026 medication administration record (MAR) revealed hydrocodone-acetaminophen was administered to the resident 43 times in June 2026. -However, hydrocodone-acetaminophen was listed in the resident’s EMR as an allergy until 6/22/26 at 6:00 p.m., when the DON updated and removed the hydrocodone (Vicodin) allergy from the EMR (see interview below). Review of Resident #36’s June 2026 MAR revealed the resident had not received any administrations of oxycodone, including l on 6/22/26, when the resident refused the medication (see resident interview above). -However, the medication was available for administration to Resident #36 from 6/16/26 to 6/22/26, even though it was listed as an allergy, creating the likelihood for the medication to be erroneously administered to the resident, who had a history of a reaction to the medication. The oxycodone medication continued to be listed as an allergy after the hydrocodone allergy was removed on 6/22/26. C. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 6/22/26 at 5:55 p.m. LPN #2 said he had offered the oxycodone medication to Resident #36 earlier that day (6/22/26) because it was ordered as a medication that could be administered to her. LPN #2 said he should have checked Resident #36’s EMR for her allergies prior to asking her if she wanted the oxycodone. The DON was interviewed on 6/22/26 at 6:05 p.m. The DON said LPN #2 should have checked Resident #36’s allergies prior to offering the oxycodone medication to the resident. The DON said the physician was contacted about the allergy and the order for oxycodone was discontinued (a few minutes prior to the interview). The DON said nursing staff should have checked Resident #36’s allergies prior to administering hydrocodone to the resident. The DON said he did not know why the hydrocodone medication had been administered to Resident #36 since May 2026 when it had been listed as an allergy in the resident’s EMR. He said the physician was contacted that afternoon (6/22/26) and had determined Resident #36 was not allergic to hydrocodone. The DON said the hydrocodone allergy was removed from Resident #36’s list of allergies. The consultant pharmacist was interviewed on 6/25/26 at 5:14 p.m. The consultant pharmacist said one of the pharmacist’s contacted the nurse (identified later as the DON) at the facility on 6/16/26, the date the oxycodone was ordered, regarding the oxycodone and hydrocodone allergies. The consultant pharmacist said the DON told the pharmacist the medications were not allergies for Resident #36 and the EMR would be updated to reflect this information. The consultant pharmacist said the pharmacist would expect the nurse to have updated the allergies at that time. The consultant pharmacist was interviewed again on 6/26/26 at 12:56 p.m. The consultant pharmacist said the pharmacy had also contacted the facility’s nursing staff on 4/29/26 to confirm whether hydrocodone was an allergy for Resident #36. The consultant pharmacist said she would expect the pharmacist to confirm Resident #36 did not have the hydrocodone allergy if the facility was administering the medication. The consultant pharmacist said she would expect nursing staff at the facility to confirm residents did not have allergies to medications with each medication that was administered.

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to:-Ensure food items in the main kitchen refrigerator were labeled and dated;-Maintain the ice scoop holder and the microwave in a sanitary condition; and, -Ensure raw meat was stored in a manner that prevented cross contamination of ready-to-eat foods. Findings include:I. Failure to properly label and date food itemsA. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 6/30/26, read in pertinent part, “Working containers holding food or food ingredients that are removed from their original packages for use in the food establishment shall be identified with the common name of the food.” (3-302.12)“Refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded.” (3-501.17)B. Facility policy and procedure The Food Storage policy, revised 2/8/21, was provided by the nursing home administrator (NHA) on 6/25/26 at 3:29 p.m. The policy revealed in pertinent part, “Each item is to be accurately dated upon receipt. When items are opened or in use,‘use-by-dates are to be labeled upon them followed by storing the item in the proper area such as the refrigerator, freezer, or dry storage area located in the kitchen.” “All items requiring refrigeration should be stored at a temperature of 36-41 degrees Fahrenheit or below and are to be dated properly.”C. ObservationsThe initial tour of the kitchen was completed on 6/22/26 at 9:05 a.m., and revealed the following:At 9:17 a.m., seven fruit cups and three strawberry cream pies were in the kitchen refrigerator without labels identifying the food item, preparation date, or discard date. During a follow-up tour of the kitchen on 6/23/26 at 4:00 p.m., the following was observed:Three fruit cups were observed in the kitchen refrigerator without labels identifying the food items, preparation date, or discard date. D. Staff interviewsThe dietary manager (DM) was interviewed on 6/23/26 at 4:01 p.m. The DM said the fruit cups were prepared the previous day and should have been labeled by the staff member who prepared them. The DM said the fruit cups were good for three days. Cook #1 was interviewed on 6/25/26 at 10:42 a.m. Cook #1 said the staff member who prepared the food was responsible for ensuring it was covered, labeled, and dated before placing it in the refrigerator. Cook #1 said the dietary aide (DA) typically prepared salads, sandwiches, and fruit cups. Cook #1 said food items that were missing preparation dates or labels should be discarded because staff would not know when the items were prepared, especially if staff had not worked for several days. Dietary aide #1 was interviewed on 6/25/26 at 11:01 a.m. Dietary aide #1 said the dietary aides were responsible for preparing fruit cups and that fruit cups were good for three days. Dietary aide #1 said prepared food items were supposed to be labeled and dated so staff would know when they were prepared and to ensure expired food was not served. Dietary aide #1 said if food items were missing preparation dates or labels, staff would have to look at meal tickets to determine when the items were prepared. Dietary aide #1 said they were not supposed to serve expired food. The DM was interviewed again on 6/25/26 at 11:55 a.m. The DM said prepared food items should be identified and dated before being placed in the refrigerator to ensure expired food was not served. The DM said all kitchen staff were responsible for ensuring prepared food items were labeled and dated before being stored in the refrigerator and whoever put the food away was responsible for labeling and dating it. The DM said unlabeled food should be discarded and staff should be educated. II. Failure to maintain the ice scoop holder and the microwave in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations (3/16/24), retrieved on 06/30/26, read in pertinent part, “Equipment food-contact surfaces and utensils shall be clean to sight and touch.” (4-601.11). “Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.” (4-601.11)“The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment.” (6-501.114)B. Facility policy and procedure The Food Storage policy, revised 2/8/21, was provided by the NHA on 6/25/26 at 3:29 p.m. The policy revealed in pertinent part, “Ice will be produced, stored, and dispensed in a manner to avoid contamination.”“Ice scoops will be stored outside of the ice dispenser in a closed, clean container or in the ice machine in the scoop storage container provided by the manufacturer. Ice scoops will be cleaned and sanitized daily.”“Employees will follow proper cleaning and sanitizing instructions for all kitchen equipment.” “Equipment and work areas should be cleaned and sanitized after use.” C. ObservationsThe initial tour of the kitchen was completed on 6/22/26 at 9:05 a.m., and revealed the following:At 9:21 a.m., the ice scoop holder contained an accumulation of white residue in the interior bottom surface of the ice scoop holder. During a follow-up tour of the kitchen on 6/24/26 at 10:45 a.m., the same white residue was observed in the interior bottom surface of the ice scoop holder. At 11:36 a.m. the interior of the microwave in the kitchen contained dried food splatter and yellow grease accumulation D. Staff interviewsCook #1 was interviewed on 6/25/26 at 10:42 a.m. Cook #1 said the microwave and the ice scoop holder were cleaned by the dietary aides or by any staff member who uses them. Cook #1 observed the interior of the microwave during the survey and said that it did not look clean. Cook #1 said she would clean the microwave. Dietary aide #1 was interviewed on 6/25/26 at 11:01 a.m. Dietary aide #1 said whoever used the microwave or the ice scoop holder was responsible for cleaning it if they made a mess. Dietary aide #1 said the microwave and the ice scoop holder should be cleaned after use because food residue and debris left on the equipment could contaminate other food or utensils and create an unsanitary condition. The DM was interviewed on 06/25/2026 at 11:55 a.m. The DM said the microwave should be cleaned frequently, especially when spills occur. The DM said the dietary aides or any staff member who used the microwave or observed spills were responsible for cleaning it. The DM said the ice machine had been working intermittently and maintenance was on site to repair it. The DM said it was everyone's responsibility to clean the ice scoop holder when residue is observed and, ultimately, it is the DS's responsibility to ensure it is cleaned to help prevent cross-contamination. III. Failure to store raw meat in a manner that prevented cross contaminationA. Professional referenceThe Colorado Retail Food Establishment Regulations (3/16/24), retrieved on 06/30/26, read in pertinent part, “Food shall be protected from cross contamination by separating raw animal foods during storage, preparation, holding, and display from: raw ready-to-eat food including other raw animal food such as fish for sushi or molluscan shellfish, or other raw ready-to-eat food such as fruits and vegetables; cooked ready-to-eat food; and fruits and vegetables before they are washed.” (3-302.11). B. Facility policy and procedure The Food Storage Policy, revised 2/8/21, was provided by the NHA on 6/25/26 at 3:29 p.m. The policy revealed in pertinent part, “When storing raw meat, it must be properly sealed and separated from all other foods during storage. It should always be below ready-to-eat foods.”“Raw meat should be stored in order of top to bottom on shelves: fish, beef, ground beef, and poultry.”C. ObservationsThe initial tour of the kitchen was completed on 6/22/26 at 9:05 a.m., and revealed the following:At 9:06 a.m. a utility cart in the cook line area contained three packages of raw beef stored on the top shelf. Directly beneath the raw beef, on the lower shelf of the same cart, was a covered pan containing a prepared salad mixture. D. Staff interviewsCook #1 was interviewed on 6/25/26 at 10:42 a.m. Cook #1 said raw meat and ready-to-eat foods should be stored separately to prevent cross-contamination. Cook #1 said raw chicken is stored on the bottom shelf of the speed rack in the walk-in cooler, raw pork and beef are stored above the chicken, and precooked foods are stored above the raw meats. Cook #1 said ready-to-eat foods and salads are stored on a separate speed rack. Cook #1 said if ready-to-eat foods were stored directly below packages of raw beef, the ready-to-eat foods should be discarded because raw meat juices could drip onto the food and cause cross-contamination, making the food unsafe to serve. Dietary aide #1 was interviewed on 6/25/26 at 11:01 a.m. Dietary aide #1 said the cooks were responsible for properly storing raw meats and ready-to-eat foods. Dietary aide #1 said storing ready-to-eat food beneath raw meat creates a risk of cross-contamination. Dietary aide #1 said if she observed ready-to-eat food stored below raw meat, she would discard the ready-to-eat food because it could have been contaminated by raw meat juices and would no longer be safe to serve. The DM was interviewed on 6/25/26 at 11:55 a.m. The DM said raw meat should be stored below ready-to-eat foods to prevent cross-contamination because storing ready-to-eat food beneath raw meat creates a risk of contamination from raw meat juices. The DM said the prepared salad mixture stored on the utility cart outside the refrigerator beneath the packages of raw beef on 6/22/26 was from the previous day and had been used for chicken wraps. The DM said she had noticed the salad in the refrigerator that morning and intended to discard it because it could not be used again.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to prevent the development and transmission of diseases and infection on two of two units. Specifically, the facility failed to:-Ensure isolation signage was correct for Resident #76’s room; -Ensure staff wore the appropriate personal protective equipment (PPE) when entering Resident #1’s room;-Ensure staff properly cleaned shared vital signs equipment between residents;-Ensure Resident #36’s reusable therapeutic cold pack was not stored in a public refrigerator with food;-Ensure a medication vial was cleaned or discarded after it had rolled across the floor; and,-Ensure hand hygiene was performed after a wrapper was picked up from the kitchen floor. Findings include:I. Facility policy and procedureThe Infection Control policy, revised 1/29/25, was provided by the nursing home administrator (NHA) on 6/22/26 at 2:17 p.m. It read in pertinent part,“All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing patient care services. Hand hygiene shall be performed in accordance with our facility’s established hand hygiene procedures. All staff shall use PPE according to established facility policy governing the use of PPE. Licensed staff shall adhere to safe injection and medication administration practices. Environmental cleaning and disinfection shall be performed according to facility policy. “A resident with an infection or communicable disease shall be placed on transmission based precautions as recommended by current CDC (Centers for Disease Control and Prevention) guidelines.“All reusable items and equipment requiring special cleaning, disinfection or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.“Isolation signs are used to alert staff, family members, and visitors of transmission based precautions.”II. Transmission based precaution signage and PPE failuresA. Professional referenceAccording to the CDC’s Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), (4/2/24), retrieved on 6/30/26, from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html,“Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs.“Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high-contact resident care activities.“Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use: central line,; urinary catheter, feeding tube, tracheostomy/ventilator; wound care: any skin opening requiring a dressing.”According to the CDC’s Precautions to Prevent Transmission of Infectious Agents, (11/22/23), retrieved on 6/30/26 from https://www.cdc.gov/infection-control/hcp/isolation-precautions/precautions.html, “Contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient’s environment.“Healthcare personnel caring for patients on contact precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment. Donning PPE (personal protective equipment) upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination.”B. Observations and staff interviewsOn 6/22/26 at 12:30 p.m. certified nurse aide (CNA) #4 entered Resident #76’s room. CNA #4 was not wearing a gown or gloves when she entered the room. CNA #4 delivered a meal tray to Resident #76. Resident #76’s room had a contact precautions sign posted on the door to alert all staff to wear gowns and gloves when entering the room. On 6/22/26 at 4:55 p.m. Resident #76’s precautions sign had been changed from contact precautions to enhanced barrier precautions (EBP). On 6/25/26 at 9:00 a.m. CNA #2 entered Resident #1’s room. CNA #2 was not wearing a gown when he entered the room. CNA #2 walked to the resident’s bedside table with a meal tray. He set the meal tray down and his clothing touched the bedside table. Resident #1’s room had a contact precautions sign posted on the door to alert all staff to use gowns and gloves when entering the room. LPN #4 was preparing to administer medications to residents and was outside of Resident #1’s room. LPN #4 said Resident #1 was on contact precautions and this required all staff to wear gowns and gloves when entering his room. LPN #4 then told CNA #2 that he should wear a gown whenever he entered Resident #1’s room. III. Failed to clean vital signs equipment between residentsA. Professional referenceThe CDC’s Recommendations for Disinfection and Sterilization in Healthcare Facilities, (2024), was retrieved on 6/30/26 from https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html#:~:text=Ensure%20that%2C%20at%20a%20minimum,once%20daily%20or%20once%20weekly. It read in pertinent part, "Clean medical devices as soon as practical after use. Perform either manual cleaning or mechanical cleaning. Perform low-level disinfection for noncritical patient-care surfaces and equipment (blood pressure cuffs) that touch intact skin."B. ObservationsOn 6/24/26 at 9:00 a.m. registered nurse (RN) #3 retrieved manual blood pressure equipment from the nurses’ station. RN #3 wrapped a blood pressure cuff around his own arm to check for size. RN #3 then took the blood pressure equipment to Resident #76’s room, wrapped the blood pressure cuff around Resident #76’s arm and checked the resident’s blood pressure. RN #3 then took the blood pressure monitoring equipment to Resident #77’s room, wrapped the blood pressure cuff around Resident #77’s arm and checked the resident’s blood pressure. -However, RN #3 did not clean the blood pressure monitoring equipment after wrapping the cuff around his own arm or after checking Resident #76’s blood pressure and Resident #77’s blood pressure. IV. Failed to ensure Resident #36’s reusable therapeutic cold pack was not stored in a public refrigerator with foodA. Resident interview and observations Resident #36 was interviewed on 6/22/26 at 2:30 p.m. Resident #36 said she placed two reusable therapeutic cold packs on her back each day. Resident #36 said she placed the reusable cold packs in a freezer every morning that was accessible to all residents. Resident #36 said that staff did not assist her with storage of the reusable cold packs. Resident #36 was interviewed again on 6/23/26 at 5:55 p.m. Resident #36 said she had placed her reusable cold packs in the freezer that morning (6/23/26). On 6/23/26 at 6:00 p.m. the refrigerator freezer for storage of residents’ food was observed. Two reusable cold packs, approximately eight by 10 inches each, were in the freezer, unlabeled and without Resident #36’s name, open to air and not in a sealed package. The reusable cold packs were near a box of popsicles. On 6/24/26 at 4:45 p.m. the reusable cold packs were observed in the same refrigerator freezer, unlabeled and open to air, next to the popsicles. B. Staff interviewRN #6 was interviewed on 6/24/26 at 5:10 p.m. RN #6 said the refrigerator freezer in the common area on the unit was for residents’ food, not residents’ reusable cold packs. RN #6 said Resident #36’s reusable cold packs should be cleaned and sanitized by staff, labeled with the resident’s name and sealed in a plastic storage bag. RN #6 said the reusable cold packs were supposed to be stored in a storage freezer on the unit that was specifically for residents’ ice packs. V. Failed to ensure a medication vial was cleaned or discarded after it was on the floorA. ObservationOn 6/24/26 at 9:35 a.m. RN #1 retrieved a box which contained a vial of tuberculin purified protein derivative (PPD) from the medication refrigerator. RN #1 removed the vial from the box and then dropped the vial on the floor. The vial rolled across the floor. RN #1 picked up the vial and set it on the counter. RN #1 then changed her gloves and performed hand hygiene. She wiped the top of the tuberculin PPDvial with an alcohol wipe and then drew up the medication in a syringe for administration. RN #1 then placed the vial back in the box and returned it to the medication storage refrigerator.-However, RN #1 did not clean the outside of the or inspect the vial for potential damage after the vial rolled across the floor of the room, prior to drawing up a dose from the vial. VI. Failed to ensure hand hygiene was performed after a wrapper was picked up from the kitchen floor A. ObservationOn 6/24/26 at 11:01 a.m. the dietary manager (DM) wiped the probe thermometer with an alcohol pad after taking food temperatures. The alcohol pad wrapper fell onto the floor. The DM picked up the wrapper from the floor, discarded the wrapper and then continued taking food temperatures of the rice, spinach, and gravy without performing hand hygiene. VII. Staff interviewsThe infection preventionist (IP) was interviewed on 6/24/26 at 9:53 a.m. The IP said Resident #76’s room should have consistently had an EBP sign on the door, not a contact precautions sign. The IP said staff might have run out of EBP signs, so they might have put a contact precautions sign on the door as a place holder. The IP said one of the nurses on the unit saw the incorrect signage and corrected it to the appropriate precautions. The IP said she would expect CNA #2 to wear a gown and gloves if he entered Resident #1’s room for any reason. The IP said if a gown was not worn in a contact precautions room, an infection could spread to others. The IP said RN #3 should have cleaned the blood pressure cuff and vital signs equipment between each use. The IP said there were disinfectant purple top wipes to clean the vital signs equipment and the equipment should have been cleaned to prevent any spread of bacteria or germs. The IP said the nursing staff or CNAs needed to clean residents’ reusable cold packs and the packs should be kept in the medication room freezer, labeled with residents’ names and in separate plastic bags for each resident. The IP said Resident #36 was provided education on 6/23/26 (during the survey) of the need for staff to clean and change out her cold packs. The IP said if a medication vial was dropped and rolled across the floor, it should be checked for breakage and the vial cleaned completely. The IP said the tuberculin PPD vial should not have been placed back into the box and into the medication refrigerator if it was not cleaned after it was on the floor. The IP said if anything was dropped on the floor, including wrappers, she would expect staff to change gloves and perform hand hygiene.

A survey prompted by #CO2717870 was completed on 6/22/26 to 6/25/26. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for one (#81) of three residents reviewed for grievances out of 37 sample residents. Specifically, the facility failed to ensure Resident #81’s grievance concerning late administration of as-needed (PRN) pain medication was documented, investigated, and resolved. Findings include:I. Facility policy and procedure The Grievances policy and procedure, revised 1/8/24, was provided by the nursing home administrator (NHA) on 6/24/26 at 4:56 p.m. It read in pertinent part, “The purpose of this policy is to ensure all patients, legal representatives/responsible parties, staff, and visitors are aware of the facility’s grievance procedure.“Each resident, resident’s representative and his or her responsible parties, family members, staff, and visitors have the right to voice complaints and/or grievances without discrimination or the fear of reprisal. Such grievances include those regarding care, treatment, or other matters related to the quality of care or quality of life.“Grievances can be communicated to a staff member either verbally or in writing.“The facility would make every effort to promptly investigate and resolve any grievances.”II. Resident #81A. Resident status Resident #81, age greater than 65, was admitted on 4/15/26. According to the June 2026 computerized physician orders (CPO), diagnoses included sepsis due to methicillin susceptible staphylococcus aureus (a severe life threatening medical emergency that occurs when a localized infection caused by a specific strain of bacteria enters the bloodstream and triggers a violent, body wide immune response, type 2 diabetes mellitus, metabolic encephalopathy (a temporary or permanent brain dysfunction caused by a chemical imbalance in the body) and muscle weakness. The 4/22/26 comprehensive assessment revealed the resident had a moderate cognitive impairment. He was dependent with toileting and transfers, required supervision or touch assistance with personal hygiene and was independent with eating. B. Resident interviewResident #81 was interviewed on 6/23/26 at approximately 12:00 p.m. Resident #81 said he had waited over four hours to receive his requested PRN pain medication a few days ago. Resident #81 said he was deeply unhappy with the situation because he was in constant pain and did not receive his medication when it was needed. Resident #81 said he reported the incident to the facility case manager the following morning, but he had not received any feedback regarding his concern. According to Resident #81, the case manager told him he was not the only resident she had heard express concerns about late medications that morning. Resident #81 said that no formal grievance form was completed at the time of the initial report or during the subsequent days. Resident #81 said that due to the delay in receiving his PRN medication, his pain increased from a pain level of 5 to a pain level of 7 on a pain scale of 1-10. C. Record reviewA review of Resident #81’s June 2026 CPO revealed the following physician’s orders for PRN pain medications:Ibuprofen oral tablet 400 milligrams (mg). Give one tablet by mouth every six hours for pain, ordered4/29/26 and discontinued 6/1/26. Ibuprofen oral tablet 600 mg by mouth every six hours as needed for pain and comfort with, ordered 6/1/26. Oxycodone HCI oral tablet 15 mg. Give 15 mg orally every six hours PRN for pain level 1 to 10; give 10 mg for pain level 1 to 6; give 15 mg for pain level 7 to 10, ordered 4/15/26. Review of Resident #81’s pain management care plan, initiated 4/15/26, revealed the resident had acute and chronic pain related to infection, type two diabetes mellitus, deep vein thrombosis, and muscle spasm. Interventions included actively listening to Resident #81’s concerns as needed; administering pain medications according to physician’s orders and monitoring for effectiveness.-A review of the facility’s Grievance Log, from 1/1/26 through 6/24/26, revealed that no entry had been documented regarding Resident #81’s reported concern about his late PRN pain medication. III. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 6/24/26 at 3:51 p.m. LPN #3 said Resident #81 had chronic pain and his PRN pain medications should be given on time when requested. LPN #3 said the grievances were followed for any concerns expressed by a resident orally or in writing. LPN #3 said that, as the unit manager, she documented all concerns brought to her attention and followed up on them. LPN #3 said she was not aware of any delay in receiving pain medications for Resident #81. The case manager was interviewed on 6/25/26 at 9:45 a.m. The case manager said the facility’s grievance process was that when a resident had a concern, the resident was encouraged to report the concern to any staff member, and staff ensured that the social services consultant was informed. The case manager said the department manager, who was responsible for the department, would handle the grievance to ensure a resolution was reached. The case manager said Resident #81 informed her of his concerns about not receiving his PRN pain medication timely when requested. The case manager said she did not remember the exact date the resident reported the incident to her. The case manager said she did not complete a grievance form and did not inform the unit manager of the incident. The NHA was interviewed on 6/25/26 at 10:15 a.m. The NHA said staff members filled out the grievance forms whenever a resident reported concerns with their stay at the facility. The NHA said concerns about care needed to be addressed immediately by the department heads. The NHA said he would then review the grievance forms to ensure the resolution was reached to the resident’s satisfaction. The NHA said the case manager should have reported and documented Resident #81’s concerns regarding the resident’s delay in receiving his PRN medication when it was requested. He said he did not understand why the case manager failed to document and follow up on the resident’s pain concerns. The NHA said he would immediately provide education on the grievance process to all the facility staff members.

Based on observations, record review and interviews, the facility failed to ensure two (#18 and #36) of three residents reviewed for medication administration out of 37 sample residents were kept free from significant medication errors. Specifically the facility failed to:-Ensure the insulin pen was primed prior to an insulin medication administration for Resident #18; and,-Ensure pain medications documented on Resident #36’s allergy list were not ordered and available for administration to the resident. Findings include:I. Failed to ensure the insulin pen was primed prior to insulin administration for Resident #18A. Professional referenceAccording to the manufacturer Eli Lilly and Company, Instructions for Use, Insulin Lispro Kwik Pen, July 2023, retrieved on 6/29/26 from https://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf, “Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. “To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with the needle pointing up. Push the dose knob in until it stops and “0” is seen in the dose window. Hold the dose knob and count to five slowly. You should see insulin at the tip of the needle.”B. Facility policy and procedureThe Insulin Pen Injections policy, revised 6/14/22, was provided by the director of nursing (DON) on 6/24/26 at 11:45 a.m. It read in pertinent part, “Remove the cap of the insulin pen. If the insulin in the pen appears cloudy, roll the pen in your hands and turn it from side to side until mixed. You do not have to roll the pen if the insulin is completely clear. Wipe the rubber stopper with an alcohol wipe. Attach a new pen needle onto the insulin pen. Prime the insulin pen. Priming means removing air bubbles from the needle, and ensures that the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the dosage knob to the two units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears.”C. Resident #181. Resident statusResident #18, age greater than 65, was admitted on 6/10/26. According to the June 2026 computerized physician orders (CPO), diagnoses included displaced fracture of right humerus (upper arm), diabetes, kidney disease and atrial fibrillation (an irregular, rapid heart rate). The 6/16/26 comprehensive assessment identified Resident #18 had moderate cognitive impairment. The comprehensive assessment revealed the resident was independent with eating, required substantial assistance with personal hygiene, toileting, showering and transferring. 2. ObservationOn 6/24/26 at 10:20 a.m. registered nurse (RN) #2 was in Resident #18’s room preparing to administer insulin Lispro to the resident. RN #2 cleaned the tip of the insulin Lispro pen with an alcohol pad, applied a new needle and then dialed the insulin pen to four units. RN #2 showed Resident #18 the pen dialed to four units, cleaned the resident’s abdomen on the left side with an alcohol swab, removed the safety cap and administered the injected medication. -RN #2 failed to prime the resident’s insulin pen per manufacturer's directions (see professional reference above) prior to administering the medication to the resident. 3. Record reviewReview of Resident #18’s June 2026 CPO revealed the following physician’s order:Insulin Lispro solution pen-injector 100 units per milliliter (ml). Inject four units subcutaneously (SQ) three times a day, ordered 6/24/26. D. Staff interviewsRN #2 was interviewed on 6/24/26 at 10:24 a.m. RN #2 said she did not prime the insulin pen prior to administering insulin to Resident #18. RN #2 said she was an agency nurse and some of the nursing facilities she worked at primed insulin pens, and others did not. RN #2 said she did not know if she needed to prime the insulin pen at this facility. RN #2 said she did not know if Resident #18 received all of the insulin dose that was ordered. The DON was interviewed on 6/24/26 at 10:37 a.m. The DON said all insulin pens should be primed prior to the administration of insulin. The DON said RN #2 should have primed the insulin pen to ensure the entire dose of insulin was administered to Resident #18. II. Failed to ensure pain medications documented on Resident #36’s allergy list were not ordered and available for administration to the residentA. Facility policy and procedureThe Allergy Identification and Management policy, initiated 1/1/24, was provided by the nursing home administrator (NHA) on 6/25/26 at 3:30 p.m. It read in pertinent part, “Patient allergy and adverse reaction information should be obtained, documented, and communicated as part of the assessment and care process.“Allergy information may be reviewed and updated as new information becomes available or when clinically appropriate.“Allergy information should be available in the medical record to support safe care and medication administration.“Review allergy information during medication reconciliation and before administering medications or treatments, as appropriate.”B. Resident #361. Resident statusResident #36, age greater than 65, was admitted on 3/12/26. According to the June 2026 CPO, diagnoses included compression fractures of vertebrae (spine), respiratory failure, heart disease and dementia. The 5/4/26 comprehensive assessment identified Resident #36 was cognitively intact. The comprehensive assessment revealed the resident required set- up assistance with eating, moderate assistance with dressing and substantial assistance with toileting, showering and transferring. 2. Resident interviewResident #36 was interviewed on 6/22/26 at 2:35 p.m. Resident #36 said earlier that day (6/22/26), the nurse offered to give her oxycodone for her pain. Resident #36 said she told the nurse she could not take the oxycodone medication because she was allergic to it. Resident #36 said oxycodone made her very sick in the past and she could not tolerate it. Resident #36 said she could take hydrocodone, but not oxycodone. 3. Record reviewA review of Resident #36’s electronic medical record (EMR) on 6/22/26 at 2:45 p.m. revealed she had allergies to oxycodone, Percocet (oxycodone combined with acetaminophen), and Vicodin (hydrocodone combined with acetaminophen). Review of Resident #36’s June 2026 CPO revealed the following physician’s orders:Hydrocodone-acetaminophen oral tablet, 5-325 milligrams (mg). Give one tablet by mouth every four hours as needed for moderate pain, ordered 5/5/26. Hydrocodone-acetaminophen oral tablet, 5-325 mg. Give two tablets by mouth every four hours as needed for severe pain, ordered 5/5/26. Oxycodone hydrochloride (HCL) tablet 5 mg. Give one tablet by mouth every four hours as needed for pain, one to 10 out of 10 (rating of pain), ordered 6/16/26 and discontinued 6/22/26 at 5:56 p.m. (during the survey)Review of Resident #36’s June 2026 medication administration record (MAR) revealed hydrocodone-acetaminophen was administered to the resident 43 times in June 2026. -However, hydrocodone-acetaminophen was listed in the resident’s EMR as an allergy until 6/22/26 at 6:00 p.m., when the DON updated and removed the hydrocodone (Vicodin) allergy from the EMR (see interview below). Review of Resident #36’s June 2026 MAR revealed the resident had not received any administrations of oxycodone, including l on 6/22/26, when the resident refused the medication (see resident interview above). -However, the medication was available for administration to Resident #36 from 6/16/26 to 6/22/26, even though it was listed as an allergy, creating the likelihood for the medication to be erroneously administered to the resident, who had a history of a reaction to the medication. The oxycodone medication continued to be listed as an allergy after the hydrocodone allergy was removed on 6/22/26. C. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 6/22/26 at 5:55 p.m. LPN #2 said he had offered the oxycodone medication to Resident #36 earlier that day (6/22/26) because it was ordered as a medication that could be administered to her. LPN #2 said he should have checked Resident #36’s EMR for her allergies prior to asking her if she wanted the oxycodone. The DON was interviewed on 6/22/26 at 6:05 p.m. The DON said LPN #2 should have checked Resident #36’s allergies prior to offering the oxycodone medication to the resident. The DON said the physician was contacted about the allergy and the order for oxycodone was discontinued (a few minutes prior to the interview). The DON said nursing staff should have checked Resident #36’s allergies prior to administering hydrocodone to the resident. The DON said he did not know why the hydrocodone medication had been administered to Resident #36 since May 2026 when it had been listed as an allergy in the resident’s EMR. He said the physician was contacted that afternoon (6/22/26) and had determined Resident #36 was not allergic to hydrocodone. The DON said the hydrocodone allergy was removed from Resident #36’s list of allergies. The consultant pharmacist was interviewed on 6/25/26 at 5:14 p.m. The consultant pharmacist said one of the pharmacist’s contacted the nurse (identified later as the DON) at the facility on 6/16/26, the date the oxycodone was ordered, regarding the oxycodone and hydrocodone allergies. The consultant pharmacist said the DON told the pharmacist the medications were not allergies for Resident #36 and the EMR would be updated to reflect this information. The consultant pharmacist said the pharmacist would expect the nurse to have updated the allergies at that time. The consultant pharmacist was interviewed again on 6/26/26 at 12:56 p.m. The consultant pharmacist said the pharmacy had also contacted the facility’s nursing staff on 4/29/26 to confirm whether hydrocodone was an allergy for Resident #36. The consultant pharmacist said she would expect the pharmacist to confirm Resident #36 did not have the hydrocodone allergy if the facility was administering the medication. The consultant pharmacist said she would expect nursing staff at the facility to confirm residents did not have allergies to medications with each medication that was administered.

A complaint survey, prompted by #CO2655766 was conducted on 11/5/25 to 12/5/2025. No deficiencies were cited. The actual survey date was 11/6/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/5/25.

A survey prompted by complaint #CO2659544 was completed 10/21/25 to 10/23/25. Two deficiencies were cited.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#1 and #5) of six residents out of 17 sample residents. Specifically, the facility failed to:-Provide timely, consistent and effective monitoring and appropriate documentation for Resident #1’s left lower leg amputation surgical incision, which resulted in the resident’s transfer to the hospital where she was hospitalized for 10 days with a diagnosis of a left below the knee amputation incision infection; and,-Obtain wound care orders for Resident #5’s skin tear in a timely manner. Resident #1 was admitted to the facility on 8/26/25 after a hospital stay for a surgical amputation of her left lower leg. Resident #1 had an initial skin assessment completed at the facility on 8/27/25 which documented the staples to the incision were intact and the wound was well approximated (edges of the skin were closed together). An 8/27/25 wound care evaluation assessment did not address the resident’s amputation site incision wound. On 8/29/25 the physician documented Resident #1 was worried the incision was getting infected. The physician documented the resident had an amputation site incision infection and ordered doxycycline (antibiotic) 100 milligrams (mg) twice a day (bid) for seven days and Rocephin (antibiotic given by injection) 1 gram (gm) one time dose and monitor the incision.-However, the Rocephin and doxycycline medications were not entered into the resident’s electronic medical record (EMR) until 8/31/25. The Rocephin was administered on 8/31/25 and the doxycycline was started on 9/1/25. The resident was not started on any antibiotics until two days after the physician noted an infection to the amputation site incision on 8/29/25. Despite the physician noting the incision site had an infection and antibiotics being ordered, there was no nursing documentation to indicate staff were consistently monitoring the resident’s infected incision for signs of a worsening infection. On 9/5/25 Resident #1 went to an appointment with the vascular surgeon who performed the left lower leg amputation. The resident was advised during that visit to go to the emergency room due to an infected amputation site incision. Resident #1 returned to the facility after the appointment and then was transferred to the hospital via non-emergent ambulance. Due to the facility’s failure to closely monitor and document the condition of Resident #1’s lower left leg amputation site incision. The resident was hospitalized for 10 days for a diagnosis of left below the knee amputation site infection and underwent washout debridement (procedure to remove infected or damaged tissue from wounds). She had a wound vacuum assisted closure (VAC) (promotes wound healing) of the incision site during her hospitalization. The infectious disease specialist was consulted during her hospital admission and a course of intravenous (IV) ertapenem (antibiotic) was ordered and completed with subsequent improvement to the resident’s amputation incision site. Resident #1 did not return to the facility. Additionally, the facility failed to obtain timely wound care orders for Resident #5, who was admitted from home with a skin tear to her left lower leg. II. Resident #5 A. Resident statusResident #5, age greater than 65, was admitted on 10/20/25. According to the October 2025 CPO, diagnoses included dementia. The 10/22/25 facility assessment revealed the resident had significant cognitive impairment. She required extensive assistance with activities of daily living (ADL). B. ObservationsOn 10/21/25 at 5:03 p.m. Resident #5 was observed with an undated loose bandage wrap sparsely covering a large gauze pad on her left lower leg. On 10/22/25 at 11:05 a.m. two hospice nurses came to check on Resident #5. They noticed the bandage to Resident #5’s leg had come undone, and proceeded to change it. The hospice nurses said Resident #5 had sustained the skin tear on her leg from a fall at her home prior to being admitted to the facility. On 10/23/25 at 9:30 a.m. WCN #1 was observed changing Resident #5’s dressing to her left lower leg skin tear. The wound was a golf-ball size skin tear on the mid-upper lateral side of her calf with a large amount of red and purple discoloration. There was an additional skin tear on the lower section of her calf that was smaller in size, but with the same dark red and purple discoloration. The skin tears were not actively bleeding and were partially scabbed over. C. Record reviewThe 10/20/25 nursing admission note documented that Resident #5 had a single wound on her left ankle. The note specified that the wound was a skin tear on her lower calf, however, the note did not address the larger skin tear on her left upper-mid calf. The note documented that the skin tear dressing was changed.-However, according to registered nurse (RN) #1 (see interview below), she did not change Resident #5’s dressing on the day the resident admitted to the facility (10/20/25), but only looked under the dressing that was already on the wound prior to her admission. -The facility failed to obtain physician’s orders for a dressing change until 10/22/25 at 11:44 a.m., two days after Resident #5 had been admitted to the facility. D. Hospice RN interviewThe hospice RN was interviewed on 10/22/25 at 11:05 a.m. The hospice RN said Resident #5 was on hospice services and was at the facility for respite care. The hospice RN said the resident had fallen while at home and sustained a skin tear to her left lower leg. The hospice RN said that the old bandage she removed had adhered to Resident #5’s skin and she had to use a wound cleaner to moisten the bandage in order to remove it. E. Staff interviewsRN #1 was interviewed on 10/22/25 at 5:40 p.m. RN #1 said she had admitted Resident #5 to the facility on 10/20/25. RN #1 said she had peeked under Resident #5’s wound dressing on her lower left leg upon her admission, but she said she did not change the dressing because she was waiting for official wound care orders. She said she expected the WCN would have put in wound care orders the following day after the resident’s admission. WCN #1 was interviewed on 10/23/25 at 10:29 a.m. WCN #1 said she saw Resident #5 on 10/21/25 but forgot to enter the wound care orders from the physician into the resident’s electronic medical record (EMR). She said she forgot to document the wound care she completed on Resident #5’s leg on 10/21/25. The DON was interviewed on 10/23/25 at 12:56 p.m. The DON said she had provided WCN #1 with education regarding correct and timely documentation of resident care.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries to prevent or heal pressure injuries for two (#9 and #7) of six residents out of 17 sample residents. Specifically, the facility failed to:- Identify, evaluate, monitor, and document a pressure ulcer for Resident #9;- Ensure Resident #9’s weekly skin assessments were accurate; and,- Ensure appropriate wound prevention interventions, including an air mattress, were consistently monitored for Resident #9 and Resident #7. Resident #9, who was at risk for skin breakdown, was admitted to the facility on 8/30/25 following a hospitalization for a right hip fracture. The admission skin assessment documented she had scattered bruising to her abdomen and a bruise to her right ear. On 9/9/25 the facility documented the resident had moisture-associated skin damage (MASD) to her coccyx and treated the area of skin damage with barrier cream. On 9/15/25 the facility documented the resident had an abrasion to her coccyx related to MASD and put a treatment order of a foam border dressing in place. However, the facility failed to identify the area of skin breakdown as a pressure injury. On 9/18/25 the facility continued to identify the area of skin breakdown to Resident #9’s coccyx as an abrasion and added medihoney (a wound treatment that can be used to get rid of slough (whitish non-viable tissue which commonly develops in Stage 3 or Stage 4 pressure wounds - see professional reference below) or necrotic (dead) tissue that can develop in wounds) the treatment order. However, the facility failed to identify the area of skin breakdown as a pressure injuryResident #9’s skin breakdown care plan failed to include an intervention of an air mattress until 9/12/25, after the resident had already developed the skin issue. Additionally, the resident’s weekly skin assessments conducted by the nursing staff were inconsistent and incomplete, frequently failing to identify the skin issue to the resident’s coccyx. On 9/22/25 Resident #9 discharged to another long-term care facility. The facility identified the resident had an unidentified wound to her coccyx upon discharge. Upon Resident #9’s admission to the receiving facility, the staff at the receiving facility documented the resident had an open area to her coccyx with slough present in the wound.-The facility failed to accurately identify a pressure wound to Resident #9’s coccyx, which developed during the resident’s stay at the facility from 8/30/25 to 9/22/25. Additionally, the facility failed to ensure staff were consistently following and/or documenting appropriate interventions, including ensuring low air loss mattress settings were in place, for Resident #7, who had a Stage 4 pressure injury to his right buttock. IV. Resident #7A. Resident statusResident #7, age less than 65, was admitted on 7/18/25. According to the October 2025 CPO, diagnoses included multiple sclerosis (MS), quadriplegia (paralysis that affects all a person’s limbs) and pressure ulcer of the right buttock stage 4 (severe wound with tissue loss exposing bone, muscles or tendons). According to the 7/28/25 facility assessment the resident was cognitively intact. The resident was dependent on staff for all activities of daily living (ADL). B. ObservationsOn 10/21/25, at 3:30 p.m., Resident #7 was lying on an air mattress with the head of the bed upright with heel boots in place. His mattress and floor were covered with flakes of skin and there was a strong unpleasant odor in the room. A white board used to pass on information had position changes every two hours written on it and indicated the resident received bathing assistance twice a week in the evening. On 10/22/25 wound care nurse (WCN) #1 and the assistant director of nursing (ADON) completed wound care on Resident #7. The room had a strong foul smell that was observable from the hallway outside of Resident #7’s room. Resident #7 had a wound vacuum (vac) covering his wound with a dressing that was intact. A small smear of a brown substance was observed on the corner of the dressing. The dressing was not labeled with the initials of the last staff member to change the dressing or the time and date of the last dressing change. The dressing was removed and revealed a deep, tunneled wound with a moderate amount of brownish-yellowish drainage. The wound bed had a slimly yellowish-brownish film covering it. The walls of the wound were beefy red. The opening of the wound appeared to have a dime-sized black spot on it. WCN #1 said the wound had improved significantly since Resident #7 had been admitted to the facility. A large reddened and peeling area along the inside and back of Resident #7’s thigh and buttocks was observed, just below the wound. The ADON glanced at it and said it was probably moisture associated skin damage (MASD). WCN #1 said the area used to be much more macerated but had improved significantly. WCN #1 dressed the wound and labeled the new dressing with her initials, and the time and date of the dressing change. During the wound care observation, the wound was not measured and barrier cream was not applied to the skin around the wound. C. Resident interview Resident #7 was interviewed on 10/21/25 at 3:30 p.m. Resident #7 said he preferred to stay in bed. He said he used to get into a chair but it was uncomfortable for him to sit up. He said he was dependent on staff for all ADLs. Resident #7 said the facility staff repositioned him when he asked for it, but did not come into his room every two hours to offer repositioning. He said he would refuse repositioning at times because he might have just eaten and did not want to lay back further. Resident #7 said he had not had a bed bath in a few weeks. He said facility staff would tell him they were getting ready to give him a bath, but then they would get too busy and never come back. He said he did not refuse bed baths. Resident #7 said he understood the importance of repositioning and bathing. D. Record reviewThe skin care plan, initiated 7/18/25, documented Resident #7 had potential for skin breakdown related to impaired mobility due to weakness and debility. The pertinent interventions included an air mattress to his bed per facility guidelines, dressing changes per physician’s order, monitoring and assisting the resident to reposition frequently, as needed or requested, and notifying the physician of any signs and symptoms of infections.-However, the October 2025 CPO documented to reposition Resident #7 throughout the shift and the October 2025 treatment administration record (TAR) documented repositioning was done twice a day. The wound care plan, initiated 7/24/25 and revised 7/29/25, documented Resident #7 had a Stage 4 pressure injury to his right buttock due to MS, quadriplegia, need for assistance for personal care, nutritional problems and staff must assist the resident with meals. The pertinent interventions included administering treatments as ordered and monitoring for effectiveness - if the resident refused treatment, conferring with the resident, the interdisciplinary team (IDT) and family to determine why and to try alternative methods to gain compliance and to document alternative methods; and documenting weekly treatments, including measurements of each area of skin breakdown’s width, length, depth, type of tissue and exudate and any other notable changes or observations. The decision care plan, initiated 7/31/25 and revised on 10/23/25 during the survey, documented Resident #7 was non-compliant with care, such as bathing, repositioning of his right buttock and refusals to work with therapy. Pertinent interventions included changing approach and recording approaches which were successful and documenting non-compliance and reporting it to the physician.-Resident #7’s care plan, diagnosis list, and July 2025 through October 2025 TARs did not include MASD or interventions to treat MASD. However, WCN #1’s assessments, from 8/19/25 and 10/22/25, documented maceration around Resident #7’s wound (see observation above for identified MASD). Review of Resident #7’s electronic medical record (EMR) and the July 2025 through October 2025 TARs revealed missing treatment documentation from 7/18/25 to 10/23/25. The following was not charted per orders:Wound VAC to right buttock, dressing change every Monday, Wednesday, Friday and PRN was not documented as being completed five times (7/21/25, 9/10/25,10/3/25, 10/10/25 and 10/13/25). Barrier cream to coccyx, periarea every shift and as needed (PRN) was not documented as being completed nine times (8/3/25, 8/11/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/3/25, 10/4/25 and 10/10/25). Wound Vac check settings and function every shift was not documented as being completed 11 times (7/20/25, 7/21/25, 8/3/25, 8/11/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/3/25, 10/4/25 and 10/10/25). Reposition side-to-side was not documented as being completed 11 times (8/3/25, 8/11/25, 8/18/25, 8/21/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/3/25, 10/4/25 and 10/10/25). Low-air-loss mattress check settings was not documented as being completed nine times (8/3/25, 8/11/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/2/25, 10/3/25 and 10/10/25). The October 2025 CPO revealed a physician’s order to check the settings and function of the low-air-loss mattress every shift. However the settings for the mattress were not documented in the physician’s order. The October 2025 TAR documented to check settings and function of the low-air-loss mattress every shift. Document with a plus sign or a dash.-There was no further documentation on what the settings should be set at or what the plus sign and dash were to indicate. The 8/12/25 skin/wound note documented Resident #7’s periwound (skin surrounding a wound) was healthy and presented with no signs or symptoms of skin breakdown or infection. The 8/15/25 skilled note documented the outer wound area was macerated. The 8/18/25 nurse practitioner (NP) progress note did not document the new finding of the macerated skin to the periwound. The 8/19/25 physician’s progress note did not document the new finding of the macerated skin to the periwound. The 8/19/25 skin/wound progress note, documented at 12:24 p.m., revealed the periwound was macerated and had a denuded (loss of the skin’s protective layer) area of 3 cm (centimeters). -There was no documentation to indicate the physician had been notified. -However the progress note dated 8/15/25 documented signs of macerated skin but WCN #1 did not assess until 8/19/25, five days later. The daily skilled progress notes through October 2025 did not document the macerated periwound. The skin/wound progress notes continued to document macerated skin to the periwound through October 2025. The progress notes did not indicate the physician had been notified of the resident’s skin deterioration. E. Staff interviewsNP #1 was interviewed on 10/22/25 at 12:50 p.m. NP #1 said she was not notified of any changes in Resident #7’s wound. She said she did not know about, and was not notified about, any concern for MASD. NP #1 said the provider should be notified of any changes to the skin or a wound. She said she relied on staff assessments, progress notes, signs and symptoms of infection and laboratory results for any changes in the treatment of the wounds. LPN #2 was interviewed on 10/22/25 at 3:30 p.m.. LPN #2 said she would check the air mattress settings by asking the resident if they were comfortable and push on the mattress to check the air pressure. She said she did not check the air mattress settings and thought she was verbally told the settings of the bed. LPN #2 said if there was a change in a resident’s skin condition she would notify the WCN. She said the WCN was responsible for notifying the physician. She said Resident #7 was particular about his care but she was not aware that he refused bed baths. She said the daily skilled note should indicate if a resident refused care. The DON was interviewed on 10/22/25 at 4:28 p.m. The DON said the floor nurse should notify the WCN of any skin concerns. She said the CNAs were educated to notify the nurse of anything abnormal to a resident’s skin. She said the nurses should document all skin conditions in the skin evaluation. The DON said if the TAR was not marked, the assumption would be that the task was not completed. WCN #1 was interviewed on 10/23/25 at 10:29 a.m. WCN #1 said she completed wound care on Resident #7 once a week and measured the wound once a week when she completed the wound care. She said if she forgot to measure a wound, then she would remove the wound dressing and redo the wound care so the wound could be measured. She said she had only changed Resident #7’s wound dressing once, on 10/22/25, although she had not obtained measurements at that time (see observations above). WCN #1 said she had changed Resident #7’s wound vac on 10/20/25, but did not document the wound care. She said the measurements she documented on 10/22/25 were actually obtained on 10/20/25. She said she did not document wound care on 10/20/25 or label the wound dressing at that time. F. Facility follow upOn 10/23/25 at 12:56 p.m. the DON said she had provided WCN #1 with education on correct documentation. She said documentation on wound care was completed and back-dated for 10/20/25 when WCN #1 said she had measured the wound.

A complaint survey, prompted by #CO2641184 and #CO2644565 was conducted on 10/21/25 to 10/23/25. Six deficiencies were cited.

Based on interviews and record review, the facility failed to ensure one (#2) of six residents out of 17 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to effectively resolve and demonstrate the facility’s response to individual grievances for Resident #2. Findings include:I. Facility policy and procedureThe Grievance policy, revised 1/8/24, was provided by the director of nursing (DON) on 10/23/25 at 3:36 p.m. It read in pertinent part, “If the complaint is verbal, it is the responsibility of the staff member who received the complaint to properly complete the grievance form on behalf of the complainant. The completed form must be provided to the executive director or designee immediately. The grievance will be given to the appropriate department manager for follow up and resolution. “All grievances will be reviewed in the morning meeting with interdisciplinary (IDT) members. The department managers are responsible for the resolution of all complaints within his or her department. The department managers will note the disposition of the grievance in writing to the executive director or designee. “It is the responsibility of the department manager in coordination with the executive director, when appropriate, to develop a process and plan for the resolution of the grievance and notify the complainant about the resolution plan. All actions taken on the grievance, including meetings with the patient, telephone calls, action plans, revisions to care plans, etc., must be documented on the grievance form. If the complainant or aggrieved party is dissatisfied with the finding and/or remedies, the executive director will make reasonable attempts to resolve the grievance. The ombudsman will be notified if the grievance is not resolved per the resident/family representative's request.”II. Resident #2A. Resident statusResident #2, age 86, was admitted on 9/16/25. According to the October computerized physician orders (CPO), diagnoses included Alzheimer’s disease, fracture of left femur, essential hypertension (high blood pressure), psychotic disturbance, mood disturbance and anxiety. The 9/22/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. B. Resident #2’s representative interviewResident #2’s representative was interviewed on 10/22/25 at 4:30 p.m. He said he had filed grievances with the facility regarding Resident #2’s physical therapy. The representative said he was concerned the weight bearing status communicated by the orthopedic surgeon was not being followed. The representative said he had not received a response to the grievance he filed. He said the director of rehabilitation (DOR) met with him but he was not satisfied with her explanation. The representative said he emailed the nursing home administrator (NHA), but he had not received a response. He said he had other concerns with the care Resident #2 received. He said he felt the facility did not resolve his concerns for Resident #2’s care. C. Record reviewA grievance form for Resident #2 was provided by the director of nursing (DON) on 10/23/25 at 2:28 p.m. The grievance form, completed by the DOR on 10/7/25, documented Resident #2’s representative was upset about the new weight-bearing order. The resident’s representative felt the therapy department changed Resident #2’s weight bearing status and not the orthopedic surgeon. The grievance form documented the therapy team provided education to the resident’s representative indicating the resident was not fully weight-bearing and Resident #2 was able to bear weight as tolerated. The grievance form documented the date the grievance was received by social services, the signature line, the substantiated and unsubstantiated line, and the NHA’s signature were left blank. It revealed Resident #2’s satisfaction was hesitant, concerned, and the comments read that the representative still believed therapy had changed the resident’s weight bearing status order. III. Staff interviewsThe NHA was interviewed on 10/23/25 at 6:48 p.m. The NHA said anyone could fill out a grievance form. He said residents and family members can turn in the grievance form to any staff or put it in the box in front of the social services office. He said once a grievance was turned in, the facility had 48 hours to resolve the grievance. He said if a resident was discharged prior to the grievance being resolved, the facility should contact the resident or representative to resolve the grievance. The NHA said based on the format of the grievance form, he was unable to show when any grievance was resolved, including the grievances filed for Resident #2, because there was no section on the form with a date when the grievance was resolved. The NHA said the words cautiously optimistic, doubtful, hesitant and concerned did not reveal if the grievance was resolved to the resident or family’s satisfaction. The NHA said before October 2025, nursing documented resident concerns as a progress note. The NHA said resident's concerns documented as a progress note should have been documented on a grievance form to ensure the grievance was resolved.

Based on record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for the resident that met professional standards of quality care for three (#2, #8 and #17) of five residents out of 17 sample residents. Specifically, the facility failed to fully develop, review with the resident and/or his responsible party and implement a person-centered baseline care plan within 48 hours of admission for Resident #2, Resident #8 and Resident #17. Findings include: I. Facility policy and procedure The Baseline Care Plan policy and procedure, revised 3/28/24, was provided by the director of nursing (DON) on 10/23/25 at 6:49 p.m. It read in pertinent part, “The baseline care plan must be developed within 48 hours of a patient’s admission. The facility must provide the patient and their representative, if applicable, with a summary of the baseline care plan.”II. Resident #2A. Resident status Resident #2, age 86, was admitted on 9/16/25. According to the October 2025 computerized physician orders (CPO), diagnoses included Alzheimer’s disease, fracture of left femur, essential hypertension (high blood pressure), psychotic disturbance, mood disturbance and anxiety. The 9/22/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The MDS assessment revealed the resident was taking anticoagulant medications, antipsychotic medications, required a mechanically altered diet, and the resident’s goal was to be discharged to the community. B. Resident #2’s representative interview Resident #2’s representative was interviewed on 10/22/25 at 4:30 p.m. Resident #2’s representative said he was really frustrated with the facility because they did not communicate when Resident #2 was admitted. He said there was miscommunication on the resident’s discharge plans, diet and physical therapy plans. He said it was even more frustrating when the facility said Resident #2 was ready to be discharged because he thought she did not have enough physical therapy. He said he had to tell the facility to cut up the resident’s food and she needed assistance. He said he wished the facility had provided more communication when she was first admitted so they could have been “on the same page.” C. Record reviewReview of Resident #2’s October 2025 CPO revealed the resident had a physician’s order for Seroquel (antipsychotic medication) 25 milligrams (mg) one time per day at bedtime for depression, ordered 9/16/25. Review of Resident #2’s baseline care plan, dated 9/16/25, revealed the following: -There was no baseline care plan, including a focus, a goal, and an intervention for psychotropic medication. -The baseline care plan identified the resident was to receive a carbohydrate-controlled diabetic diet, however it did not identify that Resident #2 required a mechanical soft diet texture. -The baseline care plan identified Resident #2 received anticoagulant medications, however, the focus, goal, and interventions for anticoagulants were not identified. -The baseline care plan for discharge planning was incomplete and the intervention for the location of where the resident wanted to be discharged to was not identified.-Review of Resident #2’s EMR on 10/23/25 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident or the resident’s responsible party was provided with a copy of the resident’s baseline care plan. The 9/19/25 social services progress note revealed the social services director (SSD) met with Resident #2. The note documented the admission assessments were completed. The SSD explained the discharge plan process and progress updates were conducted on Wednesdays and Thursdays after Tuesday's interdisciplinary team (IDT) discharge meetings. The note documented the resident was aware her discharge datewas determined by insurance, therapy progress and her medical status. The resident reported no concerns at the time and the SSD would continue to follow.-However, the SSD did not meet with Resident #2 until three days after her admission to the facility. -Additionally, the progress note did not indicate that the resident’s baseline care plan was reviewed with the resident during the meeting with the SSD or that the resident was provided with a copy of her baseline care plan.

Based on observations, record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene and good nutrition for two (#3 and #7) of five residents reviewed for ADLs out of 17 sample residents. Specifically, the facility failed to:-Ensure Resident #3 consistently received assistance with meals and showers; and, -Ensure Resident #7 received assistance with showers. II. Resident #7A. Resident statusResident #7, age less than 65, was admitted on 7/18/25. According to the July 2025 CPO, diagnoses included multiple sclerosis (MS), quadriplegia (paralysis that affects all a person’s limbs) and pressure ulcer of right buttock stage 4 (severe wound with tissue loss exposing bone, muscles or tendons). According to the 7/28/25 MDS assessment the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was dependent on staff for all activities of daily living (ADL). B. Resident interview and observationResident #7 was interviewed on 10/21/25 at 3:30 p.m. During the interview, Resident #7 was lying in bed. His mattress and floor were covered with dry, white flakes. There was a strong unpleasant odor in the room. There was a white board in the room that indicated Resident #7 was to receive baths twice a week in the evening. He said he was dependent on staff for all ADLs. Resident #7 said he had not had a bed bath in a few weeks. He said the staff would tell him they would get to his bath and then get too busy and never come back. He said he did not refuse bed baths. D. Record reviewThe bathing care plan, initiated 7/18/25 and revised 10/22/25, documented the resident agreed to receiving a shower or bed bath. Interventions included Resident #7 preferred a bed bath, frequency was two times a week. The decision care plan, initiated 7/31/25 and revised 10/23/25 (during the survey), documented the resident was non-compliant with cares such as bathing, repositioning of right buttock and refusals to work with therapy. Pertinent interventions included changing the approach and recording approaches which were successful, documenting non-compliance and reporting to the physician.-However, review of the EMR revealed there was no documentation of non-compliant behavior or successful approaches. The 8/9/25 skilled nursing note documented the resident verbalized to the nurse that he had not had a bath since his admission on 7/18/25. The October 2025 look back period (9/25/25 to 10/19/25) bathing task record revealed Resident #7 had a bath documented 9/25/25, a bath on 10/2/25 and a refusal documented 10/10/25. -It indicated Resident #7 received two out of eight opportunities. -Review of the daily skilled notes from admission to 10/21/25 did not reveal any refusals of bed baths. E. Staff interviewsWound care nurse (WCN) #1 was interviewed on 10/22/25 at 10:50 a.m. WCN #1 said it was important to bathe residents with skin conditions. She said the odor coming from Resident #7’s room has not changed since she started in July 2025. WCN #1 said she did not believe the odor was from the wound and said he may need more hygiene care and bathing. She said the staff may not be cleaning him well enough after a bowel movement. She said she saw feces on the dressing while she changed it on 10/22/25. WCN #1 said she was not aware Resident #7 had refused bed baths. LPN #2 was interviewed on 10/22/25 at 3:30 p.m. LPN #2 said Resident #7 was particular about his care but she was not aware he had refused bed baths. LPN #2 said if a resident refused any care, treatment or medication, the refusal should be documented in the daily skilled note. DON was interviewed on 10/22/25 at 4:28 p.m. DON said the IDT monitors the bathing schedule about every two weeks. She said if a resident refused they are not offered another bath until their next scheduled bath day. DON said if a resident refused a bath they would fill out a shower form.-However, there were no shower forms for Resident #7 during that time period.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#1 and #5) of six residents out of 17 sample residents. Specifically, the facility failed to:-Provide timely, consistent and effective monitoring and appropriate documentation for Resident #1’s left lower leg amputation surgical incision, which resulted in the resident’s transfer to the hospital where she was hospitalized for 10 days with a diagnosis of a left below the knee amputation incision infection; and,-Obtain wound care orders for Resident #5’s skin tear in a timely manner. Resident #1 was admitted to the facility on 8/26/25 after a hospital stay for a surgical amputation of her left lower leg. Resident #1 had an initial skin assessment completed at the facility on 8/27/25 which documented the staples to the incision were intact and the wound was well approximated (edges of the skin were closed together). An 8/27/25 wound care evaluation assessment did not address the resident’s amputation site incision wound. On 8/29/25 the physician documented Resident #1 was worried the incision was getting infected. The physician documented the resident had an amputation site incision infection and ordered doxycycline (antibiotic) 100 milligrams (mg) twice a day (bid) for seven days and Rocephin (antibiotic given by injection) 1 gram (gm) one time dose and monitor the incision.-However, the Rocephin and doxycycline medications were not entered into the resident’s electronic medical record (EMR) until 8/31/25. The Rocephin was administered on 8/31/25 and the doxycycline was started on 9/1/25. The resident was not started on any antibiotics until two days after the physician noted an infection to the amputation site incision on 8/29/25. Despite the physician noting the incision site had an infection and antibiotics being ordered, there was no nursing documentation to indicate staff were consistently monitoring the resident’s infected incision for signs of a worsening infection. On 9/5/25 Resident #1 went to an appointment with the vascular surgeon who performed the left lower leg amputation. The resident was advised during that visit to go to the emergency room due to an infected amputation site incision. Resident #1 returned to the facility after the appointment and then was transferred to the hospital via non-emergent ambulance. Due to the facility’s failure to closely monitor and document the condition of Resident #1’s lower left leg amputation site incision. The resident was hospitalized for 10 days for a diagnosis of left below the knee amputation site infection and underwent washout debridement (procedure to remove infected or damaged tissue from wounds). She had a wound vacuum assisted closure (VAC) (promotes wound healing) of the incision site during her hospitalization. The infectious disease specialist was consulted during her hospital admission and a course of intravenous (IV) ertapenem (antibiotic) was ordered and completed with subsequent improvement to the resident’s amputation incision site. Resident #1 did not return to the facility. Additionally, the facility failed to obtain timely wound care orders for Resident #5, who was admitted from home with a skin tear to her left lower leg. II. Resident #5 A. Resident statusResident #5, age greater than 65, was admitted on 10/20/25. According to the October 2025 CPO, diagnoses included dementia. The 10/22/25 MDS assessment revealed the resident had significant cognitive impairment with a BIMS score of three out of 15. She required extensive assistance with activities of daily living (ADL). B. ObservationsOn 10/21/25 at 5:03 p.m. Resident #5 was observed with an undated loose bandage wrap sparsely covering a large gauze pad on her left lower leg. On 10/22/25 at 11:05 a.m. two hospice nurses came to check on Resident #5. They noticed the bandage to Resident #5’s leg had come undone, and proceeded to change it. The hospice nurses said Resident #5 had sustained the skin tear on her leg from a fall at her home prior to being admitted to the facility. On 10/23/25 at 9:30 a.m. WCN #1 was observed changing Resident #5’s dressing to her left lower leg skin tear. The wound was a golf-ball size skin tear on the mid-upper lateral side of her calf with a large amount of red and purple discoloration. There was an additional skin tear on the lower section of her calf that was smaller in size, but with the same dark red and purple discoloration. The skin tears were not actively bleeding and were partially scabbed over. C. Record reviewThe 10/20/25 nursing admission note documented that Resident #5 had a single wound on her left ankle. The note specified that the wound was a skin tear on her lower calf, however, the note did not address the larger skin tear on her left upper-mid calf. The note documented that the skin tear dressing was changed.-However, according to registered nurse (RN) #1 (see interview below), she did not change Resident #5’s dressing on the day the resident admitted to the facility (10/20/25), but only looked under the dressing that was already on the wound prior to her admission. -The facility failed to obtain physician’s orders for a dressing change until 10/22/25 at 11:44 a.m., two days after Resident #5 had been admitted to the facility. D. Hospice RN interviewThe hospice RN was interviewed on 10/22/25 at 11:05 a.m. The hospice RN said Resident #5 was on hospice services and was at the facility for respite care. The hospice RN said the resident had fallen while at home and sustained a skin tear to her left lower leg. The hospice RN said that the old bandage she removed had adhered to Resident #5’s skin and she had to use a wound cleaner to moisten the bandage in order to remove it. E. Staff interviewsRN #1 was interviewed on 10/22/25 at 5:40 p.m. RN #1 said she had admitted Resident #5 to the facility on 10/20/25. RN #1 said she had peeked under Resident #5’s wound dressing on her lower left leg upon her admission, but she said she did not change the dressing because she was waiting for official wound care orders. She said she expected the WCN would have put in wound care orders the following day after the resident’s admission. WCN #1 was interviewed on 10/23/25 at 10:29 a.m. WCN #1 said she saw Resident #5 on 10/21/25 but forgot to enter the wound care orders from the physician into the resident’s electronic medical record (EMR). She said she forgot to document the wound care she completed on Resident #5’s leg on 10/21/25. The DON was interviewed on 10/23/25 at 12:56 p.m. The DON said she had provided WCN #1 with education regarding correct and timely documentation of resident care.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries to prevent or heal pressure injuries for two (#9 and #7) of six residents out of 17 sample residents. Specifically, the facility failed to:- Accurately identify, document, evaluate and monitor a pressure ulcer for Resident #9;- Ensure Resident #9’s weekly skin assessments were documented thoroughly and accurately; and,- Ensure appropriate wound prevention interventions, including an air mattress, were implemented timely and consistently monitored for function and settings for Resident #9 and Resident #7. Resident #9, who was at risk for skin breakdown, was admitted to the facility on 8/30/25 following a hospitalization for a right hip fracture. The admission skin assessment documented she had scattered bruising to her abdomen and a bruise to her right ear. On 9/9/25 the facility documented the resident had moisture-associated skin damage (MASD) to her coccyx and treated the area of skin damage with barrier cream. On 9/15/25 the facility documented the resident had an abrasion to her coccyx related to MASD and put a treatment order of a foam border dressing in place. However, the facility failed to identify the area of skin breakdown as a pressure injury. On 9/18/25 the facility continued to identify the area of skin breakdown to Resident #9’s coccyx as an abrasion and added medihoney (a wound treatment that can be used to get rid of slough (whitish non-viable tissue which commonly develops in Stage 3 or Stage 4 pressure wounds - see professional reference below) or necrotic (dead) tissue that can develop in wounds) the treatment order. However, the facility failed to identify the area of skin breakdown as a pressure injury. Resident #9’s skin breakdown care plan failed to include an intervention of an air mattress until 9/12/25, after the resident had already developed the skin issue. Additionally, the resident’s weekly skin assessments conducted by the nursing staff were inconsistent and incomplete, frequently failing to identify the skin issue to the resident’s coccyx. On 9/22/25 Resident #9 discharged to another long-term care facility. The facility identified the resident had an unidentified wound to her coccyx upon discharge. Upon Resident #9’s admission to the receiving facility, the staff at the receiving facility documented the resident had an open area to her coccyx with slough present in the wound.-The facility failed to accurately identify a pressure wound to Resident #9’s coccyx, which developed during the resident’s stay at the facility from 8/30/25 to 9/22/25. Additionally, the facility failed to ensure staff were consistently following and/or documenting appropriate interventions, including ensuring low air loss mattress settings were in place, for Resident #7, who had a Stage 4 pressure injury to his right buttock. IV. Resident #7A. Resident statusResident #7, age less than 65, was admitted on 7/18/25. According to the October 2025 CPO, diagnoses included multiple sclerosis (MS), quadriplegia (paralysis that affects all a person’s limbs) and pressure ulcer of the right buttock stage 4 (severe wound with tissue loss exposing bone, muscles or tendons). According to the 7/28/25 MDS assessment the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was dependent on staff for all activities of daily living (ADL). B. ObservationsOn 10/21/25, at 3:30 p.m., Resident #7 was lying on an air mattress with the head of the bed upright with heel boots in place. His mattress and floor were covered with flakes of skin and there was a strong unpleasant odor in the room. A white board used to pass on information had position changes every two hours written on it and indicated the resident received bathing assistance twice a week in the evening. On 10/22/25 wound care nurse (WCN) #1 and the assistant director of nursing (ADON) completed wound care on Resident #7. The room had a strong foul smell that was observable from the hallway outside of Resident #7’s room. Resident #7 had a wound vacuum (vac) covering his wound with a dressing that was intact. A small smear of a brown substance was observed on the corner of the dressing. The dressing was not labeled with the initials of the last staff member to change the dressing or the time and date of the last dressing change. The dressing was removed and revealed a deep, tunneled wound with a moderate amount of brownish-yellowish drainage. The wound bed had a slimly yellowish-brownish film covering it. The walls of the wound were beefy red. The opening of the wound appeared to have a dime-sized black spot on it. WCN #1 said the wound had improved significantly since Resident #7 had been admitted to the facility. A large reddened and peeling area along the inside and back of Resident #7’s thigh and buttocks was observed, just below the wound. The ADON glanced at it and said it was probably moisture associated skin damage (MASD). WCN #1 said the area used to be much more macerated but had improved significantly. WCN #1 dressed the wound and labeled the new dressing with her initials, and the time and date of the dressing change. During the wound care observation, the wound was not measured and barrier cream was not applied to the skin around the wound. C. Resident interview Resident #7 was interviewed on 10/21/25 at 3:30 p.m. Resident #7 said he preferred to stay in bed. He said he used to get into a chair but it was uncomfortable for him to sit up. He said he was dependent on staff for all ADLs. Resident #7 said the facility staff repositioned him when he asked for it, but did not come into his room every two hours to offer repositioning. He said he would refuse repositioning at times because he might have just eaten and did not want to lay back further. Resident #7 said he had not had a bed bath in a few weeks. He said facility staff would tell him they were getting ready to give him a bath, but then they would get too busy and never come back. He said he did not refuse bed baths. Resident #7 said he understood the importance of repositioning and bathing. D. Record reviewThe skin care plan, initiated 7/18/25, documented Resident #7 had potential for skin breakdown related to impaired mobility due to weakness and debility. The pertinent interventions included an air mattress to his bed per facility guidelines, dressing changes per physician’s order, monitoring and assisting the resident to reposition frequently, as needed or requested, and notifying the physician of any signs and symptoms of infections.-However, the October 2025 CPO documented to reposition Resident #7 throughout the shift and the October 2025 treatment administration record (TAR) documented repositioning was done twice a day. The wound care plan, initiated 7/24/25 and revised 7/29/25, documented Resident #7 had a Stage 4 pressure injury to his right buttock due to MS, quadriplegia, need for assistance for personal care, nutritional problems and staff must assist the resident with meals. The pertinent interventions included administering treatments as ordered and monitoring for effectiveness - if the resident refused treatment, conferring with the resident, the interdisciplinary team (IDT) and family to determine why and to try alternative methods to gain compliance and to document alternative methods; and documenting weekly treatments, including measurements of each area of skin breakdown’s width, length, depth, type of tissue and exudate and any other notable changes or observations. The decision care plan, initiated 7/31/25 and revised on 10/23/25 during the survey, documented Resident #7 was non-compliant with care, such as bathing, repositioning of his right buttock and refusals to work with therapy. Pertinent interventions included changing approach and recording approaches which were successful and documenting non-compliance and reporting it to the physician.-Resident #7’scare plan, diagnosis list, and July 2025 through October 2025 TARs did not include MASD or interventions to treat MASD. However, WCN #1’s assessments, from 8/19/25 and 10/22/25, documented maceration around Resident #7’s wound (see observation above for identified MASD). Review of Resident #7’s electronic medical record (EMR) and the July 2025 through October 2025 TARs revealed missing treatment documentation from 7/18/25 to 10/23/25. The following was not charted per orders:Wound VAC to right buttock, dressing change every Monday, Wednesday, Friday and PRN was not documented as being completed five times (7/21/25, 9/10/25,10/3/25, 10/10/25 and 10/13/25). Barrier cream to coccyx, periarea every shift and as needed (PRN) was not documented as being completed nine times (8/3/25, 8/11/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/3/25, 10/4/25 and 10/10/25). Wound Vac check settings and function every shift was not documented as being completed 11 times (7/20/25, 7/21/25, 8/3/25, 8/11/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/3/25, 10/4/25 and 10/10/25). Reposition side-to-side was not documented as being completed 11 times (8/3/25, 8/11/25, 8/18/25, 8/21/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/3/25, 10/4/25 and 10/10/25). Low-air-loss mattress check settings was not documented as being completed nine times (8/3/25, 8/11/25, 8/26/25, 9/6/25, 9/9/25, 10/1/25, 10/2/25, 10/3/25 and 10/10/25). The October 2025 CPO revealed a physician’s order to check the settings and function of the low-air-loss mattress every shift. However the settings for the mattress were not documented in the physician’s order. The October 2025 TAR documented to check settings and function of the low-air-loss mattress every shift. Document with a plus sign or a dash.-There was no further documentation on what the settings should be set at or what the plus sign and dash were to indicate. The 8/12/25 skin/wound note documented Resident #7’s periwound (skin surrounding a wound) was healthy and presented with no signs or symptoms of skin breakdown or infection. The 8/15/25 skilled note documented the outer wound area was macerated. The 8/18/25 nurse practitioner (NP) progress note did not document the new finding of the macerated skin to the periwound. The 8/19/25 physician’s progress note did not document the new finding of the macerated skin to the periwound. The 8/19/25 skin/wound progress note, documented at 12:24 p.m., revealed the periwound was macerated and had a denuded (loss of the skin’s protective layer) area of 3 cm (centimeters). -There was no documentation to indicate the physician had been notified. -However the progress note dated 8/15/25 documented signs of macerated skin but WCN #1 did not assess until 8/19/25, five days later. The daily skilled progress notes through October 2025 did not document the macerated periwound. The skin/wound progress notes continued to document macerated skin to the periwound through October 2025. The progress notes did not indicate the physician had been notified of the resident’s skin deterioration. E. Staff interviewsNP #1 was interviewed on 10/22/25 at 12:50 p.m. NP #1 said she was not notified of any changes in Resident #7’s wound. She said she did not know about, and was not notified about, any concern for MASD. NP #1 said the provider should be notified of any changes to the skin or a wound. She said she relied on staff assessments, progress notes, signs and symptoms of infection and laboratory results for any changes in the treatment of the wounds. LPN #2 was interviewed on 10/22/25 at 3:30 p.m.. LPN #2 said she would check the air mattress settings by asking the resident if they were comfortable and push on the mattress to check the air pressure. She said she did not check the air mattress settings and thought she was verbally told the settings of the bed. LPN #2 said if there was a change in a resident’s skin condition she would notify the WCN. She said the WCN was responsible for notifying the physician. She said Resident #7 was particular about his care but she was not aware that he refused bed baths. She said the daily skilled note should indicate if a resident refused care. The DON was interviewed on 10/22/25 at 4:28 p.m. The DON said the floor nurse should notify the WCN of any skin concerns. She said the CNAs were educated to notify the nurse of anything abnormal to a resident’s skin. She said the nurses should document all skin conditions in the skin evaluation. The DON said if the TAR was not marked, the assumption would be that the task was not completed. WCN #1 was interviewed on 10/23/25 at 10:29 a.m. WCN #1 said she completed wound care on Resident #7 once a week and measured the wound once a week when she completed the wound care. She said if she forgot to measure a wound, then she would remove the wound dressing and redo the wound care so the wound could be measured. She said she had only changed Resident #7’s wound dressing once, on 10/22/25, although she had not obtained measurements at that time (see observations above). WCN #1 said she had changed Resident #7’s wound vac on 10/20/25, but did not document the wound care. She said the measurements she documented on 10/22/25 were actually obtained on 10/20/25. She said she did not document wound care on 10/20/25 or label the wound dressing at that time. F. Facility follow upOn 10/23/25 at 12:56 p.m. the DON said she had provided WCN #1 with education on correct documentation. She said documentation on wound care was completed and back-dated for 10/20/25 when WCN #1 said she had measured the wound.

Based on observations, record review and interviews the facility failed to provide appropriate treatment and services to residents diagnosed with dementia for three (#17, #5 and #3) of five residents out of 17 sample residents. Specifically the facility failed to:-Develop a person-centered care plan to meet Resident #17’s dementia care needs;-Ensure Resident #5 was provided activities to meet her preferences; and,-Develop and implement a person-centered care plan to meet Resident #3’s dementia care needs. Findings include:I. Facility policy and procedureThe Care of the Cognitively Impaired policy, reviewed on 9/22/25, was provided by the director of nursing (DON) on 10/23/25 at approximately 3:00 p.m. “Ensuring adequate medical care, diagnosis, and supports based on diagnosis; “Ensuring that the necessary care and services are person-centered and reflect the resident’s goals, while maximizing the resident’s dignity, autonomy, privacy, socialization, independence, choice, and safety; and, “Utilizing individualized, non-pharmacological approaches to care (purposeful and meaningful activities). Meaningful activities are those that address the resident’s customary routines, interests, preferences, and choices to enhance the resident’s well-being. “Identify, address, and/or obtain necessary services for the dementia care needs of residents; “Develop and implement person-centered care plans that include and support the dementiacare needs, identified in the comprehensive assessment; “Develop individualized interventions related to the resident’s symptomology and rate of progression (providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks); “Review and revise care plans that have not been effective and/or when the resident has a change in condition; “Modify the environment to accommodate resident care needs; and,“Achieve expected improvements or maintain the expected stable rate of decline.”II. Resident #17 A. Resident statusResident #17, age 74, was admitted on 10/16/25. According to the October 2025 computerized physician orders (CPO), diagnoses included mild neurocognitive disorder due to known physiological conditions with behavioral disturbance. The 10/22/25 minimum data set (MDS) assessment revealed the resident had short term memory problems and had moderately impaired cognition per staff assessment. The MDS indicated the resident did not have any behaviors. B. ObservationsOn 10/21/25 around 10:00 a.m. Resident #17 sat at the nurse’s station next to a staff member. The resident and staff member chatted while the staff charted on her computer. She encouraged the resident to stay seated with her and utilize a “busy board.”-The staff did not provide Resident #17 with his preferred activities that were listed on the care plan (see care plan below). On 10/21/25 at approximately 11:00 a.m. Resident #17 was walking around the nurses’ station by himself. He entered another resident’s room. The other resident shrieked, the staff immediately went over to Resident #17 and asked him to leave the other resident’s room. He left the room. The staff walked and talked with him around the nurses’ station.-The staff did not provide Resident #17 with any person-centered interventions to prevent him from wandering into other resident’s rooms. C. Record reviewResident #17’s cognitive deficit care plan, revised on 10/17/25, revealed the following pertinent interventions: allowing the resident ample time to absorb and respond to information, allowing the resident to make as many choices as possible with his care, assisting the resident in performing and/or completing a task or activity that they can not do, avoiding changes in the resident’s environment, explaining all procedures and treatments prior to completing them, providing a calm environment and structured routine, reorienting the resident as needed. Residents #17’s activity care plan, revised 10/17/25, revealed the resident had problems or concerns that may affect the resident’s involvement in activities. Pertinent interventions included encouraging the resident to participate in group and individual activities. The care plan documented the resident enjoyed arts and crafts, games and puzzles, television (TV) and movies, listening to music, being outdoors, visits with family and friends, and physical activity. -However, observations revealed the staff did not offer the resident his preferred activities (see observations above). D. Staff interviewsThe social services director (SSD) was interviewed on 10/23/25 at 9:32 a.m. The SSD said Resident #17’s daughter lived out of state. The SSD said the facility had a meeting scheduled for that day (10/23/25) to discuss the resident’s placement. The SSD said the resident was placed on a one-to-one care giver to ensure he was safe. She said she was not aware if there had been a care plan developed to address the resident’s dementia needs. She said having a one-to-one caregiver sit with him was not the best way to address the resident’s dementia needs. She said she was not sure how new staff were provided dementia training. LPN #1 was interviewed on 10/23/25 at 3:20 p.m. She said another resident, Resident #3, had to be moved to a different floor of the building because he and Resident #17 did not get along. She said that on 10/22/25 and 10/23/25 Resident #3 became agitated and yelled at the nurses’ station, which triggered Resident #17. She said Resident #17 threw objects, yelled at the resident and staff and made threats. She said on both occasions they were able to redirect the residents away from each other. She said they redirected Resident #17 by having staff talk with him. The activities director (AD) was interviewed on 10/23/25 at approximately 5:30 p.m. The AD said when a resident was admitted to the facility, he conducted an assessment to determine what the resident liked to do. He said he invited the residents to group activities. He said some of the residents preferred individual activities such as puzzles or reading in their rooms. The AD said Resident #17 did not do well in group activities. He said Resident #17 often became agitated and did not stay. He said Resident #17 did not have a special care plan to meet his dementia needs. Registered nurse (RN) #2 was interviewed on 10/23/25 at 5:45 p.m. She said that typical interventions for dementia care were to offer assistance with the restroom, check for incontinence, offer food and fluids, let the resident sit at the nurse’s station and to redirect the resident. She said sometimes they will offer books, magazines, word puzzles, the “busy board” which is a board with a fidget spinner, locks and other miscellaneous items designed for dementia patients to occupy their time. She said the main focus was to redirect the residents. She said when Resident #17 tried to go into another resident’s room, they would try to redirect him by encouraging him to walk and talk with staff, or by offering him soda. Licensed practical nurse (LPN) #3 was interviewed on 10/23/25 at 5:47 p.m. LPN #3 said Resident #17 often walked around the nurses’ station and halls. He said Resident #17 had tried to leave the unit before, but had never made it out of the building to his knowledge. He said if the resident did try to leave, a staff member would hopefully see him and bring him back. He said if he made it as far as the lobby, then the receptionist would bring him back. He said Resident #17 was well known by everyone in the building. The DON was interviewed on 10/23/25 at 6:00 p.m. The DON said Resident #17 was placed on a one-to-one caregiver, since he was really agitated and going into other residents’ rooms. She said the one-to-one caregiver was helping with the resident’s agitation. The DON said the staff gave Resident #17 a Rubix cube yesterday and he threw it. The DON said they had tried fidget boxes too. The DON said Resident #17 did not staff in the activities. The DON said Resident #17 had a lot of hallucinations. The DON said the staff were provided dementia training at the yearly skills fair. III. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on 10/20/25. According to the October 2025 CPO, diagnoses included dementia. The 10/22/25 MDS revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. She required extensive assistance with activities of daily living (ADLs). The MDs indicated the resident spoke english. B. ObservationsOn 10/21/25 at approximately 10:40 a.m. Resident #5 was lying in bed on her back trying to get out of bed. She was yelling “help.” A few minutes later a staff member went into the room to assist her. She was seen later that day, around lunchtime, idly sitting in a wheelchair at the nurses station staring downwards. She was seated away from the counters and appeared to have no activities nearbyAt 5:03 p.m. Resident #5 was yelling for help while she laid in her bed. The unidentified staff at the nurses’ station said it was Resident #5 yelling again, and did not immediately get up to help. Resident #5 yelled for help for approximately five minutes before the staff assisted her. During a continuous observation on 10/22/25, beginning at 9:35 a.m. and ending at 1:35 p.m. the following was observed:At 9:35 a.m. Resident #5 was sleeping in her bed. At 10:15 she was sleeping in her recliner with the TV on a Spanish speaking channel. -However, Resident #5 did not speak Spanish. At approximately 11:05 a.m. a registered nurse (RN) from an outside hospice provider checked on the resident. At 11:28 a.m. the hospice RN changed the TV channel to an English channel. -The resident was lying in bed with a Spanish speaking channel playing for over an hour. The facility failed to provide person-centered interventions for Resident #5. C. Record reviewResident #5’s activity care plan, initiated on 10/21/25, revealed she enjoyed listening to music, social events and activities, spiritual activities, arts and crafts, and being outdoors. Pertinent interventions were to provide her assistance with her activity supplies, to make sure that they are convenient for her to use and to encourage her to participate in her activities of interest. Resident #5’s social isolation care plan, initiated on 10/21/25, revealed the following pertinent interventions assisting Resident #5 to and from activities and encouraging her to participate in activities of interest with others. III. Resident #3A. Resident statusResident #3, age greater than 65, was admitted to the facility on 9/17/25. According to the October 2025 CPO, diagnoses included anxiety disorder, other symptoms and signs involving cognitive functions and awareness and benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland) with lower urinary tract symptoms. The 9/30/25 MDS assessment revealed the resident had severely impaired cognition with a BIMS score of three out of 15. The resident was dependent on staff for most of the activities of daily living (ADL). The assessment revealed the resident had behavior for difficulty focusing attention, being easily distractible or having difficulty keeping track of what was said, and the resident's thinking disorganized or incoherent. B. ObservationsDuring a continuous observation on 10/22/25, beginning at 9:30 a.m. and ending at 1:15 p.m., the following was observed:At 9:30 a.m. Resident #3 was lying in bed with his door open. At 10:10 a.m. an unidentified certified nurse aide (CNA) stood at the room entrance, looked into Resident #3’s room for less than 30 seconds, and then left. At 11:02 a.m. LPN #1 entered Resident #3’s and provided care to the resident. Then LPN #1 assisted Resident #3 to the lobby by the elevators on the third floor and offered him a cup of drink. At 11:18 a.m. an unidentified CNA sat with Resident #3 at the lobby for a few minutes. At 12:07 p.m. an unidentified CNA brought the resident his lunch. -During the observation, Resident #3 was not provided with any person-centered activities to meet his dementia care needs. During a continuous observation on 10/22/25, beginning at 3:50 p.m. and ending at 6:00 p.m., the following was observed:At 3:50 p.m. Resident #3 was talking with an unidentified staff in the lobby on the first floor. Then they went upstairs on the third floor and Resident #3 stayed a bit in the nurse station talking with staff. At 4:04 p.m. the unidentified CNA assisted Resident #3 to his room. The unidentified CNA assisted Resident #3 in shaving and grooming. Resident #3 later wheeled himself to the hallway and was observed talking to the staff for a while before going back to his room. He stayed in his room sitting in his wheelchair until dinner time. At 5:05 p.m. an unidentified CNA brought the resident dinner. -During the observation, Resident #3 was not provided with any person-centered activities to meet his dementia care needs. At 5:19 p.m. Resident #3 finished eating dinner. On 10/23/25 at 9:10 a.m. Resident #3 was observed sitting by the window with his pants down to the knee. Resident #3 said he had breakfast. At 9:21 a.m. Resident #3 came into the hallway and became combative with staff when they attempted to assist him in pulling up his pants. The staff just walked away at that time. At 10:57 a.m. Resident #3 was moved to the second floor for safety reasons because another resident tried to fight him.-The facility did not provide Resident #3 with any person-centered activities. B. Record reviewThe activities care plan, initiated 9/19/25 and revised 10/7/25, included a care focus for social isolation. Pertinent interventions included one-to-one visits from activities as needed, allowing/encouraging resident to communicate his feelings regarding attended activities, assisting the resident to and from activities of choice and encouraging resident to participate in activities of interest with others. The behavior care plan, initiated 9/19/25 and revised 10/7/25, documented Resident #3 had a potential for mood disturbances. Pertinent interventions included administering medications as per physician's orders, providing distraction/redirection as needed, and providing support and reassurance. The wandering care plan, initiated 9/21/25 and revised 10/7/25, revealed Resident #3 had a history of wandering in a new environment and elopement. Pertinent interventions included reorienting and redirecting resident as needed, providing and involving resident in activities directed at resident's specific interests, monitoring resident‘s whereabouts regularly as needed to ensure safety and documenting any attempts at elopement and notifying physician and responsible party.-The care plan did not document any person-centered interventions to address Resident #3’s dementia care needs. The 10/4/25 nursing note revealed Resident #3 was verbally aggressive to the nurse while passing medications. Resident #3 attempted to strike at the nurse. The nurse asked Resident #3 to refrain from his behavior and redirect him. The weekly activity progress note, dated 10/20/25, revealed Resident #3 had been watching television, exercising as directed by therapy staff/resting to recover, ambulating in hiswheelchair and participating in coffee cart and check-in visits. He had declined additional activity supplies and was offered activities this week. Resident #3 had not expressed satisfaction or dissatisfaction with his recreational needs being met. The 10/21/25 physician assistant (PA) note revealed an assessment of dementia with behavioral disturbances/ psychosis for Resident #3. Resident #3 hit a CNA, was verbally aggressive, his behaviors were difficult to control and displayed exit seeking behaviors. The 10/23/25 progress note revealed Resident #3 was moved to the second floor for safety reasons. D. Staff interviewsCNA #1 was interviewed on 10/23/25 at 2:10 p.m. CNA #1 said Resident #3 often became combative with the CNAs when they were providing care. CNA #1 said Resident #3 did not let staff assist him with toileting or hygiene. CNA #1 said Resident #3 sometimes wore briefs, but Resident #3 would not allow staff to physically check the briefs during their rounds. CNA #1 said Resident #3 was moved to the second floor for safety reasons on 10/23/25 because another resident tried to fight him. LPN #1 was interviewed on 10/23/25 at 3:25 p.m. LPN #1 said Resident #3 required supervision while allowing Resident #3 to clean himself. She said on 10/23/25 Resident #3 allowed them to clean him as he was very unkempt. LPN #1 said Resident #3 sometimes did not wear briefs during daytime as he was able to use the toilet, but he wore briefs at night. LPN #1 said Resident #3 was yelling at her, which upset another resident. She said that resident attempted to confront Resident #3. LPN #1 said she notified her manager who decided to move Resident #3 to the second floor for safety reasons. The AD was interviewed on 10/23/25 at approximately 5:30 p.m. The AD said Resident #3 spoke Spanish and English. He said he had offered Resident #3 puzzles, but he did not like them. The AD said he had tried to keep Resident #3 busy, but had not found anything that he liked so far. The AD said the facility did not have any Spanish speaking activities. The DON was interviewed on 10/23/25 at 6:00 p.m. The DON said Resident #3 became combative during care and resisted care if he did not recognize the staff member. He said to de-escalate the situation, he would show Resident #3 his badge, explain the care that was going to be provided, and offer Resident #3 a cup of coffee. The DON said the staff needed to approach Resident #3 at his level and he was more willing to listen and allow staff to assist him.

A complaint survey, prompted by #CO38708, #CO38794 and #CO39206 was conducted on 2/17/25 to 2/18/25. No deficiencies were cited.

A complaint survey, prompted by #CO37966 was conducted on 2/17/25 to 2/18/25. 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 survey was completed on 9/16/24 for all previous deficiencies cited on 8/1/24. The facility is in compliance with all regulations surveyed.

The Colorado Department of Public Safety conducted this initial Life-Safety survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag #K000) are informational only, and are a representation of the facility's general characteristics. This facility is a three story Type II (111) structure that is protected throughout by an NFPA 13 automatic fire suppression systems and is classified as fully sprinklered. The facility is licensed for 80 beds. This survey conducted on August 29th, 2024 was for compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code (2012 edition) Chapter 19, "Existing Health Care Occupancies;" NFPA 99, Health Care Facilities Code (2012 edition); and all referenced standards. The facility will meet these requirements when all deficiencies are corrected. The deficiencies cited were discussed with the Maintenance Director during the exit conference conducted at the end of the on-site survey.

Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain firewalls in accordance with NFPA 101, 8.3.1.2.1. East stairwell- fire stopping needed around piping 2. Therapy storage- fire-stopping systems needed on wall joists and wall 3. FACP- fire-stopping systems needed 8.3.2.3 Interior walls and partitions of nonsymmetrical construction shall be evaluated from both directions and assigned a fire resistance rating based on the shorter duration obtained in accordance with ASTM E 119, Standard Test Methods for Fire Tests of Building Construction and Materials, or ANSI/UL 263, Standard for Fire Tests of Building Construction and Materials. When the wall is tested with the least fire-resistive side exposed to the furnace, the wall shall not be required to be subjected to tests from the opposite side. 8.3.1.3 Walls used as fire barriers shall comply with Chapter 7 of NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. West stairs storage in the stairwell 2. Portable liquid oxygen or storage in egress path by the kitchen. NFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101, 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7NFPA 99 11.7.3.2 Containers shall not be placed in the following areas:(1) Where they can be tipped over by the movement of a door(2) Where they interfere with foot traffic(3) Where they are subject to damage from falling objects(4) Where exposed to open flames and high-temperature devicesThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and staff interviews during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 1011. Emergency lighting: no annual 90-minute inspection report available for review 2. Exit Lights: no annual 90-minute inspection report available for reviewNFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 1/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2.1. Kitchen - Cooking appliances are not supplied with an approved system for return after maintenance or cleaning. 2. Suppression heads caps not secured to nozzles NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer installation instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. The fire alarm paperwork for the panel is incomplete, and the elevator detectors were not tested during the annual inspection or in 2023. NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, 14.3.1 Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with NFPA 13. NFPA 251. The sprinkler riser room is missing a sprinkler calculation plate. 2. No Hydraulic Design Information on signs on for system(wet, antifreeze systems). 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legibleThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with NFPA 13. NFPA 251. North loaded sprinkler heads 2. Case manager office- escutcheon plates need to be flush with the ceiling. 3. ADL- sprinkler escutcheon plates 4. Missing current annual inspection report 5. Missing Backflow valve inspection report NFPA 25, 5.2.1.1.5 Escutcheons and cover plates for recessed, flush, and concealed sprinklers shall be replaced with their listed escutcheon or cover plate if found missing during the inspection. NFPA 25 5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.1213.4.4.2 Testing. (Dry Systems)13.4.4.2.1* The priming water level shall be tested quarterly. 13.4.4.2.2* Each dry pipe valve shall be trip tested annually during warm weather. 13.4.4.2.2.1 Dry pipe valves protecting freezers shall be trip tested in a manner that does not introduce moisture into the piping in the freezers. 13.4.4.2.2.2* Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service. 13.4.4.2.2.3* During those years when full flow testing in accordance with 13.4.4.2.2.2 is not required, each dry pipe valve shall be trip tested with the control valve partially open. NFPA 25 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.31. 3rd Floor North Fire door won ' t latch. 2. Activity rooms on all floors' doors are missing door closers. NFPA 101, 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility did not maintain oxygen storage in accordance with NFPA 99. 1. Oxygen storage room is missing signs for empty and full bottles. 2. Portable liquid oxygen tank is stored under nurses station 3. Portable liquid oxygen tank concentrators in room 309NFPA 99 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. NFPA 99 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. 11.7.4.2 One liquid oxygen portable container [limited to 1.5 L (0.396 gal) capacity] per patient is permitted to be stored or used in a patient bed location or patient care room without having to meet the fire separation requirements of 11.7.4.1. NFPA 11.7.3.2 Containers shall not be placed in the following areas:(1) Where they can be tipped over by the movement of a door(2) Where they interfere with foot traffic(3) Where they are subject to damage from falling objects(4) Where exposed to open flames and high-temperature devicesThis deficiency can potentially affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference

Based on observation and record review during the survey, it was determined that the facility failed to maintain the backup emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110.1. Missing corrected coolant inspection report 2. Missing annual load bank test Based on record review and staff interviews during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8. NFPA 110, Section 8.3.8. A fuel quality test shall be performed at least annually using applicable ASTM standards or the manufacturer ' s recommendations. NFPA 110-8.4 Operational Inspection and Testing. 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the avail- able EPSS load and shall be exercised annually with supplemen- tal loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.