Wellsprings Care Center

F 0584

room was not cleaned everyday.

Level of Harm - Minimal harm or potential for actual harm

The resident who resided in room [ROOM NUMBER] was interviewed on 9/9/25 at 1:30 p.m. She said she did not have soap or towels in her bathroom. She said she did not feel these items were replaced timely.

Residents Affected - Some

C. Staff interviews

The MTD was interviewed on 9/8/25 at 12:28 p.m. The MTD said he was not aware of the floor issue in room [ROOM NUMBER] until it was brought to his attention during the survey. He said the loose tiles and brown liquid could be from mopping the floors and the water settled in between the tiles and became rusty.

He said the brown fluid could have been there for quite awhile. The MTD said the floor was an easy fix and

he would replace the tiles. The MTD said the residents' rooms were cleaned daily with the floors being mopped, bathrooms cleaned and wiping down of surface areas. He said the rooms were scheduled for monthly deep cleans, which had a more in-depth cleaning checklist.

The floor technician was interviewed on 9/9/25 at 11:52 a.m. The floor technician said the smell coming from the floor in resident room [ROOM NUMBER] was urine seeping from under the tiles.

The NHA was interviewed on 9/10/25 at 1:00 p.m. The NHA said the liquid under the tiles was not rusted water but urine. She said the residents should have been moved out of the room until all the affected areas

in the room were cleaned and treated. She said she would have them moved to complete the maintenance

on the floor properly.

HK #2 was interviewed on 9/11/25 at 9:30 a.m. She requested for another staff member, the social services assistance (SSA), to interpret because she read and spoke very little English. HK #2 said she did not have

a cleaning checklist on her cart. She said there was a checklist for rooms that received a deep clean. She said the checklist was filled out after the shift. She said the checklists were kept in a binder in the MTD's office. HK #2 said the checklist and the cleaning bottles on her cart were written in English.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wellsprings Care Center

3636 S Pearl St Englewood, CO 80113

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

intervention for residents (see interview above). The nursing home administrator (NHA) was interviewed on 9/11/25 at 12:11 p.m. The NHA said that after each fall, the IDT evaluated the root cause, interventions used, whether the interventions were effective or not and new interventions to try. The NHA said Resident #5's care plan should have been updated after the facility initiated new interventions and she acknowledged

the care plan should have been updated after Resident #5's August 2025 falls and the staff should know where to find the interventions. The NHA said even residents who are independent smokers, should be periodically observed for safe smoking practices. She was unaware of Resident #48 and #68's smoking issues.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wellsprings Care Center

3636 S Pearl St Englewood, CO 80113

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759

Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or potential for actual harm

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%).Specifically, the facility had a medication error rate of 8%, or two errors out of 25 total opportunities for error.Findings include:I. Facility policy and procedureThe Medication Administration policy, dated 8/4/25, was provided by the nursing home administrator (NHA) on 9/10/25 at 10:02 a.m. It read in pertinent part, Resident medications are administered in an accurate, safe, timely, and sanitary manner. Verify the medication label against the medication administration record (MAR) for accuracy of drug frequency, duration, strength, and route. The nurse is responsible to read and follow precautionary or instructions on prescription labels. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. Report any discrepancies to

the pharmacy. Do not administer the medication until the discrepancy is resolved. Never administer medications from an unmarked container.II. ObservationsOn 9/10/25 at 9:08 a.m., registered nurse (RN) #2 was dispensing medications to Resident #31. RN #2 dispensed one tablet of Aspirin (blood thinner) 81 milligrams (mg) enteric coated (EC - a polymer barrier applied to oral medication that prevents it from dissolving in the highly acidic stomach environment) into a medication cup. RN #2 poured a cup of water and handed the water and medication cup to Resident #31. Resident #31 took the medication.On 9/10/25 at 9:08 a.m. RN #2 was dispensing medication to Resident #59. RN #2 dispensed one tablet of Paliperidone (antipsychotic) EC 6 mg into a medication cup. RN #2 poured a cup of water, walked into Resident #59's room and handed him the cup of medication and water. Resident #59 took the medication.III. Record reviewReview of Resident #31's September 2025 computerized physician orders (CPO) revealed the resident had a physician's order for Aspirin 81 mg chewable tablets.-However, RN #2 administered an enteric coated Aspirin to Resident #31 instead of chewable aspirin (see observation above). Review of Resident #59's September 2025 CPO revealed the resident had a physician's order for Paliperidone EC 6 mg tablet. Take 2 tablets in the afternoon. -However, RN #2 dispensed one tablet of Paliperidone to Resident #59 during the morning administration pass (see observation above).IV. Staff interviewsThe regional clinical resource (RCR) was interviewed on 9/11/25 at 2:30 p.m. The RCR said a lower dose of an administered medication could lessen the effect of the medication. The RCR confirmed Resident #59's order for Paliperidone was for two tablets instead of one tablet. The RCR said Resident #31's physician's order for Aspirin read chewable tablets, however, she said the resident did not need a chewable table.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wellsprings Care Center

3636 S Pearl St Englewood, CO 80113

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

a water cup from a stack of cups located on the left side of the medication cart. LPN #3 poured water into

the cup from a water pitcher sitting on top of the medication cart. LPN #3 picked up the cup of water and

the medication cup containing Resident #24's medications and walked toward the resident's room. Upon entering Resident #24's room, LPN #3 handed him the medication cup and the cup of water. LPN #3 verified Resident #24 took his medication. LPN #3 threw the cup of water and the medication cup away and exited Resident #24's room. -LPN #3 did not perform hand hygiene during the preparation of Resident #24's medication, upon entering

the resident's room or upon exiting the resident's room.

C. Staff interviews RN #2 was interviewed on 9/10/25 at 9:31 a.m. RN #2 said hand hygiene should be performed before,

during and after medication preparation. She said hand hygiene should also be performed before and after medications were administered to a resident. RN #2 said hand hygiene should be performed to decrease

the risk of transmitting organisms and help reduce the risk of infection.

LPN #3 was interviewed on 9/10/25 at 1:17 p.m. LPN #3 said hand hygiene should be performed before and after all resident care. LPN #3 said hand hygiene was important because it helped decrease the risk of infection.

The RCR was interviewed on 9/11/25 at 2:30 p.m. The RCR said facility staff were supposed to perform hand hygiene when going in and out of a resident room and also between glove use. The RCR said proper hand hygiene was important to help prevent the transmission of organisms.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wellsprings Care Center

3636 S Pearl St Englewood, CO 80113

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

#1 said the shower head had always leaked since she was hired, and that was the reason the staff put a trash can under it to catch the water.

The NHA and the regional maintenance director were interviewed together on 9/11/25 at 11:30 a.m. while touring the shower rooms. The NHA and the regional maintenance director could not identify the black substance on the wall in the first floor shower room (nearest to the business office) or the black substance

in the second floor shower room (nearest to resident room [ROOM NUMBER]) in the place of the missing caulking. The regional maintenance director said the black substance in both shower rooms should have been inspected and tested for possible mold. The NHA said it was her expectation that a work order would be written for a leaking shower head to prevent water damage from prolonged dripping and that any suspicious black substance in the shower rooms would be tested for identification and treatment.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wellsprings Care Center

3636 S Pearl St Englewood, CO 80113

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0923

Have enough outside ventilation via a window or mechanical ventilation, or both.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations and interviews, the facility failed to ensure adequate outside ventilation by means of windows, or mechanical ventilation for two out of four shower rooms. Specifically, the facility failed to ensure ventilation fan covers were kept clean and operational in the resident shower rooms. Findings include:A.

Professional referenceAccording to the U.S. Department of Energy's Office of Energy Efficiency and Renewable Energy, April 2021 retrieved on 9/19/25 from: https://docs.nrel.gov/docs/fy21osti/79150.pdf., Proper ventilation helps reduce the concentration of bioaerosols (bioaerosols consist of aerosols originated biologically such as metabolites, toxins, or fragments of microorganisms), which can be particularly important in nursing homes due to the presence of vulnerable adults. Good ventilation can improve the health and wellbeing of the residents by reducing infection risks and preventing respiratory issues. By ensuring proper ventilation, nursing homes can significantly enhance the safety and quality of life for their residents. B. Observations On 9/7/25 at 7:28 a.m. during the initial walk through of the shower rooms, the following was observed:The first floor tub and shower room, nearest to the business office, revealed there was no air flow coming from the ventilation fan in the shower room. The ventilation fan wall cover was covered with a thick layer of what resembled gray dust. The first floor shower room, nearest to resident room [ROOM NUMBER], revealed there was no air flow coming from the ventilation fan in the shower room.On 9/9/25 at 11:35 a.m. the following was observed:The first floor tub and shower room, nearest to

the business office, revealed there was no air flow coming from the ventilation fan in the shower room. The ventilation fan wall cover was covered with a thick layer of what resembled gray dust. The first floor shower room, nearest to resident room [ROOM NUMBER], revealed there was no air flow coming from the ventilation fan in the shower room.C. Staff interviewsThe regional maintenance director was interviewed on 9/11/25 at 11:30 a.m. while touring the shower rooms. The regional maintenance director said the facility used a mechanical ventilation system. He said the ventilation system prevented condensation risks by pulling moisture laden air out of the room. The regional maintenance director said if a ventilation system was not operational in a humid environment, it could contribute to the growth of mold. He said to ensure the ventilation system was working properly in the rooms and shower rooms, a piece of paper could be put up to the vent and if there was proper air flow, the paper would be pulled to the vent. The regional maintenance director said the ventilation fan and cover should be cleaned every six months. After inspecting the first floor tub and shower room ventilation cover, the regional maintenance director acknowledged there was not any air flow and the ventilation cover had not been cleaned within the last six months. After inspecting the first floor shower room ventilation cover, the regional maintenance director acknowledged there was not any air flow.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet