LAKEWOOD VILLA

A survey for Incident #2627549 was conducted on 10/27/25 to 12/9/25. No deficiencies were cited. The actual survey exit date was 10/27/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider on 12/9/25.

A complaint survey, prompted by #CO2578322, #CO2579471 and Incident #2581317 was completed on 8/6/25. No deficiencies were cited.

A survey for Incident #40204 was conducted on 7/7/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure two (#1 and #2) of eight residents reviewed for abuse out of eight sample residents were free from abuse. Specifically, the facility failed to ensure Resident #1 and Resident #2 were free from abuse by each other. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 7/7/25 at 11:00 a.m. It read in pertinent part, "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator or to other officials according to state law. "The individual conducting the investigation as a minimum reviews the documentation and evidence, reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident, reviews all events leading up to the alleged incident and documents the investigation completely and thoroughly. The follow up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified." II. Physical abuse between Resident #1 and Resident #2 on 5/12/25. A. Facility investigation The facility investigation was provided by the NHA on 7/7/25 at 12:30 p.m. The investigation documented the NHA responded to a commotion from staff that occurred in the entrance of the front dining room. When the NHA arrived, the registered nurse (RN) on duty was standing by Resident #2 at the dining room entrance holding his glasses. At this time, Resident #1 was sitting at the table nearest to the dining room entrance. The NHA asked what happened. The staff present, including one certified nurse aide (CNA), one dietary aide and a RN , said that they did not witness the event but there was an event that occurred between Resident #1 and Resident #2. The NHA interviewed both residents following the event. Resident #1 said that he was walking to the dining room for dinner and Resident #2 kicked his shin when he walked by, then grabbed at his shirt and hit his chest. The NHA asked what happened next and Resident #1 said that he acted in self defense and hit Resident #2 to stop Resident #2 from grabbing his shirt. The NHA asked Resident #1 if he remembered if he hit Resident #2 with an open or closed hand. Resident #1 said he did not remember that detail. Resident #2 said he did not fully remember what happened and that Resident #1 came at him. The investigation documented the event was not caught on the facility's camera. The RN present said Resident #1 told her the same things that he communicated to the NHA but he told the RN he slapped Resident #2. B. Resident #1 1. Resident status Resident #1, age less than 65, was admitted on 8/20/24. According to the July 2025 computerized physician orders (CPO), diagnoses included dementia, obesity, hypertension (high blood pressure), restlessness and agitation. The 2/22/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was independent with mobility and for meals and needed moderate assistance with hygiene and set up assistance with other activities of daily living (ADL). 2. Record review Resident #1's dementia care plan, initiated 8/7/24, documented he had impaired cognit

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A revisit survey was completed on 5/7/25 for all previous deficiencies cited on 3/25/25. The facility is in compliance with all regulations surveyed.

An onsite revisit survey was conducted and all deficiencies have been corrected. No other deficiencies written and no response is necessary.

A complaint survey, prompted by #CO39217 and Incident #39384, Incident #39405, Incident #39406 and Incident #39426 was completed on 3/17/25 to 3/25/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure four (#2, #3, #6 and #9) of nine residents reviewed for abuse out of 13 sample residents were kept free from abuse. Specifically, the facility failed to:-Protect Resident #2 from physical abuse by Resident #3;-Protect Resident #6 and Resident #3 from physical abuse from each other; and, -Protect Resident #9 from physical abuse by Resident #3. Findings include: I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation policy and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 3/24/25 at 2:00 p.m. The policy read in pertinent part, "Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. "The resident abuse program consists of a facility-wide commitment and resource allocation to support protecting residents from abuse by:-Developing and implementing policies and protocols to prevent and identify abuse, neglect and exploitation, ensure adequate staffing and oversight to prevent burnout, stressful working situations and high turnover rates;-Conduct employee background checks;-Establishing and maintaining a culture of compassion and caring for all residents;-Providing staff education and training on abuse;-Implementing measures to address factors that lead to abuse;-Identifying and investigating all possible incidents of abuse;-Protecting residents from further harm during investigations; -Reviewing allegations of abuse during monthly quality assurance and performance improvement (QAPI) meetings; and,-Involving the resident council in monitoring and evaluating the facility's abuse prevention program." II. Facility investigations of abuse incidentsA. Incident of physical abuse by Resident #3 towards Resident #2 on 2/13/25The 2/13/25 abuse investigation report was provided by the clinical resource nurse (CRN) on 3/24/25 at 9:50 a.m. It documented there was a witnessed, physical altercation between two residents (Resident #2 and Resident #3). The residents were separated, assessed, placed on frequent checks and their care plans were updated with new interventions. The staff assisted Resident #2 to the Red Rocks unit for an activity. The staff took turns watching Resident #3 on the Columbine (co-ed) unit. Resident #2 sustained an abrasion and bruise to her left eyebrow but declined care. Resident #3 was interviewed by the NHA on 2/13/25 at 2:28 p.m. Resident #3 was unable to answer the NHA's questions appropriately. Resident #2 was interviewed by the NHA on 2/13/25 at 2:47 p.m. Resident #2 made a punching motion and pointed to her face when asked if any of her fellow residents had ever physically harmed her. Resident #2 was unable to appropriately answer the NHA's other questions. Eight additional residents were interviewed and did not have additional information. Housekeeper (HK) #1, who witnessed the altercation, said she was sweeping the dining room and Resident #2 was in a dining room chair. Resident #3 was sitting on a pink sofa chair. Resident #3 stood up and walked over to Resident #2. With a closed fist, Resident #3 hit Resident #2 three times on the eye. HK #1 separated the two residents and Resident #3 tried to hit her. A therapist and certified nurse aide (CNA) responded and the situation was de-escalated. The business office manager (BOM) took Resident #2 up front to the Valentine's Day party and Resident #3 grabbed the broom and started sweeping the hallway. The facility substantiated the incident. B. Incident of physical abuse between Resident #3 and Resident #6 on 2/16/25The 2/16/25 abuse investigation was provided by the CRN on 3/24/25 at 9:50 a.m. It documented there was a witnessed physical altercation between Resident #3 and Resident #6. The residents were separated and assessed. Resident #6 was assisted to his room and Resident #3 stayed with a CNA in the dining room until he went to bed. The residents's care planswere updated with new interventions. Resident #3 had a new, small abrasion on his elbow upon assessment. Resident #3 was interviewed by the BOM on 2/17/25 at 11:08 a.m. Resident #3 was unable to answer the BOM's questions appropriately. Resident #6 was interviewed by the BOM on 2/17/25 at 11:37 a.m. He answered "no" when asked if he had recently been upset by an interaction with a fellow resident at the facility, had felt uncomfortable, threatened or fearful by any fellow residents or had been harmed by any fellow residents. He had nothing additional to say. Eight residents were interviewed and had no additional information. CNA #5 made a witness statement on 2/16/25 at 10:56 p.m. CNA #5's witness statement documented that she was in the dining room. She said Resident #3 got up from his nap and came to the dining room. She said she was standing by a table. She said Resident #6 was sitting at another table but got up and began wandering. She said Resident #3 wandered over in the direction of where Resident #6 was wandering. The residents ran into each other and began arguing and yelling. Resident #3 pushed Resident #6 away. Resident #6 then grabbed at Resident #3 and pushed him hard. She said this caused Resident #3 to fall to the floor on his buttocks and tailbone. The nurse and another CNA helped the witness separate the two residents. The assisting CNA helped Resident #6 to his room where he remained for the rest of the night. The witness (CNA #5) stayed with Resident #3 until the nurse assessed him and got him up from the ground. Resident #3 did not hit his head but scraped his elbow on the wall. The facility substantiated the incident. C. Incident of physical abuse by Resident #3 towards Resident #9 on 3/24/25On 3/24/25 at 9:55 a.m. (during the survey), Resident #3 was walking around while pushing a dining room chair in the Columbine unit. Resident #9 walked in front of the chair and sat down in the chair. Resident #3 tried pushing the chair forward and was not able to. Resident #3, with an open palm, slapped Resident #9 on the right side of the head. This incident was reported to licensed practical nurse (LPN) #1 on 3/24/25 at 9:57 a.m. and reported to the NHA on 3/24/25 at 10:02 a.m. LPN #1 separated the two residents and assessed each resident. The NHA said she would start an internal abuse investigation. III. Resident #3 - assailant and victimA. Resident statusResident #3, age 74, was admitted on 12/4/24. According to the March 2025 computerized physician's orders (CPO), diagnoses included unspecified dementia with agitation, chronic obstructive pulmonary disease, low back pain and weakness. According to the 12/11/24 minimum data set (MDS) assessment the resident had short term and long term memory problems and his cognitive skills for daily decision making were severely impaired through staff assessment. He was dependent on staff for toileting and dressing. He was independent with ambulation. The MDS assessment documented Resident #3 had physical behavior symptoms directed towards others, verbal behavioral symptoms directed toward others and other behavioral symptoms not directed at others every one to three days. B. Record reviewResident #3's cognitive impairment care plan, initiated 12/18/24, revealed he had impaired cognitive function related to dementia with behaviors. Interventions included monitoring and reporting changes in cognitive function to his physicians, reviewing medications and using task segmentation to support short term memory deficits. Resident #3's behavior care plan, initiated 12/23/24 and revised 3/21/25, revealed he had the potential to be verbally and physically aggressive related to dementia. Interventions added after the 2/13/25 incident included for staff to provide Resident #3 with meaningful activities, including sweeping with supervision and reading the menus that were posted. Interventions added after the 2/16/25 incident included encouraging Resident #3 to participate in goal oriented tasks, offering snacks and drinks throughout the day and referring Resident #3 to therapy for sensory integration. The skin assessment completed on 2/16/25 documented Resident #3 had a new bruise on his left elbow. The 2/13/25 nursing note documented the nurse was notified that Resident #3 was aggressive towards another resident (Resident #2). Resident #3 was unable to explain what happened. The residents were separated and frequent checks were initiated. Resident #3's representative was notified of the incident. The 2/16/25 nursing note documented that a CNA notified the nurse that Resident #3 and another resident were yelling in each other's faces. Resident #3 pushed the other resident so that resident (Resident #6) retaliated and pushed Resident #3 to the floor. Resident #3 hit his left elbow on the ground. The CNA called the nurse and they separated both residents and the nurse assessed both residents. Resident #3 denied pain and the nurse assisted him to lift himself from the floor. Resident #3 sustained light bruising to his left elbow and a dry dressing was applied on it. The nurse notified the physician, the director of nursing (DON) and the NHA. IV. Resident #2 - victimA. Resident status Resident #2, age 85, was admitted on 1/29/25. According to the March 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances, chronic kidney disease, mood disorder and chronic pain. The 2/5/25 MDS assessment revealed the resident had short and long term memory impairment and her cognitive skills for daily decision making were moderately impaired, per staff assessment. Resident #2 was independent with ambulation and required supervision with transfers, hygiene, dressing and toileting. The MDS assessment documented Resident #2 had physical behavior symptoms directed towards others, verbal behavioral symptoms directed toward others and other behavioral symptoms not directed at others every one to three days. B. Record review Resident #2's behavior care plan, initiated 2/14/25, revealed the resident had verbal aggression. The interventions included administering medications as ordered, letting Resident #2 clean-up after meals, allowing the resident choices regarding her care, analyzing key times and triggers and what de-escalated her, assessing and anticipating the resident's needs, assessing coping skills and support systems, offering evening activities, providing sensory integration from occupational therapy, redirecting the resident away from high-stimulus areas, completing sleep tracking, speech therapy to work on communication and intervening when resident became agitated. The skin assessment completed on 2/13/25 documented Resident #2 had a new bruise and abrasion to her left eyebrow. The 2/13/25 nursing progress note documented that the nurse was notified that Resident #2 was the non-aggressor in a resident-to-resident altercation. Resident #2 was unable to describe what happened. The residents were separated for safety. Resident #2's representative, the DON, the physician and the NHA were notified. Frequent checks were initiated. V. Resident #6 - assailant and victimA. Resident status Resident #6, age less than 65, was admitted on 2/10/25 and passed away on 3/12/25. According to the March 2025 CPO, diagnoses included cerebral infarction (disrupted blood flow to the brain), unspecified dementia with psychotic disturbance, muscle weakness and type 2 diabetes. The 2/14/25 MDS assessment revealed the resident was not assessed for a brief interview for mental status or cognitive skills for daily decision making. He was dependent on staff for eating, hygiene, toileting and dressing. He could ambulate independently. The MDS assessment indicated Resident #6 did not have any physical or verbal behaviors. B. Record review Resident #6's behavior care plan, initiated 2/17/25, revealed Resident #6 had the potential to be physically aggressive related to dementia and poor impulse control. Hehad vision deficits which contributed to his wandering and spatial awareness. Interventions included administering medications as ordered, analyzing times of the day and triggers that contributed to his behaviors, assessing for the residents needs, assessing the resident for sensory deficits, providing occupational therapy for communication and sensory integration, providing physical therapy, providing speech therapy, giving the resident choices and activities, modifying the environment to make Resident #6 comfortable and reducing agitation and intervening when Resident #6 got agitated before the behavior escalated. The 2/16/25 nursing note documented that a CNA noticed Resident #6 and another resident yelling in each other's faces. Resident #3 pushed Resident #6. Resident #6 retaliated and pushed Resident #3 on the floor. Resident #3 hit his left elbow on the ground. The CNA called the nurse and they separated both residents. The physician, the DON and the NHA were notified. VI. Resident #9 - victimA. Resident status Resident #9, age less than 65, was admitted on 11/15/22. According to the March 2025 CPO, diagnoses included paranoid schizophrenia, osteoarthritis and dementia with behavioral disturbances. The 1/16/25 MDS assessment revealed the resident's cognitive skills for daily decision making were moderately impaired and he had short term and long term memory problems, through staff assessment. He was dependent on staff for hygiene, toileting, showering and dressing. He could ambulate independently. The MDS assessment indicated Resident #9 did not have any physical and verbal behaviors. B. Record review Resident #9's behavior care plan, initiated 6/16/23 and revised 8/28/23, documented Resident #9 had the potential for behavior problems related to his dementia. He had a history of physical aggression and redirection could be difficult at times. Interventions included a chart review from the pharmacist as needed, providing distraction with pleasant activities, encouraging Resident #9 to wear his eyeglasses, completing frequent rounding, providing individual activities, such as watching movies and providing a resident-specific activity box. VII. Staff interviews CNA #4 was interviewed on 3/24/25 at 1:40 p.m. CNA #4 said Resident #3 was very aggressive when he was first admitted to the facility. She said medication adjustments seemed to have started to calm his behaviors down. She said he still acted aggressive often and he was physically aggressive towards the residents that got in his personal space. She said that Resident #3 hit everybody and he did not target certain residents. CNA #4 said he sundowned (behavior changes caused by dementia) around 3:00 p.m. and that was usually when his behaviors got worse. The DON, the CRN and the NHA were interviewed together on 3/24/25 at 3:30 p.m. The NHA said she verbally educated staff on Resident #3's behavior interventions each time he got new interventions added. She said he was reviewed at monthly psychology pharmaceutical (psych pharm) meetings, weekly at-risk meetings and at the monthly QAPI meetings with the interdisciplinary (IDT) team. She said the facility identified that one of Resident #3's triggers was when he was woken up in the morning. She said the facility implemented interventions to let him sleep as long as he wanted and to wake on his own. The DON said the facility was working with the pharmacist and Resident #3's physician to adjust his medications and get him on the right medication regimen to ensure he maintained his quality of life while keeping his behaviors stable. The NHA said she had sent a referral for Resident #3 to work with a psychiatrist and that Resident #3 had been unable to participate. Resident #3's physician (PHY) was interviewed on 3/25/25 at 11:25 a.m. The PHY said he thought Resident #3's diagnosis was frontal lobe vascular dementia which was consistent with his behaviors and he would update the resident's diagnosis. He said he had beenworking with Resident #3 to get him on the right medication regimen since he was admitted. He said Resident #3 was gradually getting better with his behaviors. He said the staff that worked with him full-time knew him well and were able to redirect him. The PHY said he received calls from the agency staff regarding Resident #3's behaviors because they did not know him as well. The medical director (MD) was interviewed on 3/25/25 at 11:45 a.m. He said Resident #3 had dementia and would never be cured of his disease. He said just like other diseases, he had exacerbations with his behaviors. He said the staff were working with him to get him on the right medication regimen and the right interventions that worked for him. The MD said the goal was to minimize Resident #3's behaviors without sedating him to the point he had no behaviors. CNA #2 was interviewed on 3/25/25 at 8:35 a.m. CNA #2 said Resident #3 was not having any behaviors so far that morning (3/25/25). She said he refused his shower and they let him refuse because he could get aggressive. She said he got aggressive when other people got in his way or took his food off his plate. She said Resident #9 took food from other resident's plates in the dining room, so they had to keep Resident #3 and Resident #9 separated in the dining room. She said the two residents (Resident #9 and Resident #3) did not get along. CNA #2 said the staff redirected Resident #3 when he got aggressive with snacks, books and reading menus. The DON was interviewed a second time on 3/25/25 at 1:43 p.m. The DON said she felt like the facility was progressing with Resident #3 in the right direction. She said it had been a process to figure out Resident #3's triggers and what he responded well too. She said the facility had been working on getting information from staff and educating the staff regarding Resident #3. She said the staff kept other residents free from harm while residing with Resident #3 by knowing when Resident #3 was up and active, keeping an eye on him, redirecting him with reading material or activities when he was aimlessly wandering, being aware of his stimuli and keeping a close eye on him when he was in the dining room. She said she had not noticed any of the victims of Resident #3's incidents having any changes in their behaviors or mood. The DON said she educated the agency staff about Resident #3's patterns and triggers and also had them review a binder prior to their shift with the facility's policies.

A revisit survey was completed on 2/5/25 for all previous deficiencies cited on 12/19/24. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on January 13, 2025 for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies."This structure is a one (1) story, Type II (000) (II-B) construction. The facility was constructed in 1956 and has no basement. The facility is licensed 57 beds and the census on the date of this survey was 40. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. This facility is classified as fully sprinklered. The results of this survey was discussed with the Administrator and Maintenance staff member during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Discharge from Exits requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) During the tour of the facility, the Back Unit Courtyard Exit was not clear of obstructions and did not provide an unobstructed path to the public way. Items including garden hoses, garden hose reels, raised garden beds, and topsoil on the sidewalks either obstructed or drastically reduced the width of the sidewalk. 2) During the facility tour, the walkway from the front to the back unit had snow on the walking surface. The staff could not identify a specific date it last snowed. Only the ground in the shade had no snow, indicating the walking surface was not cleared because the snow was not covering all surfaces. The walking path shall be clear and maintained at all times. Life Safety Code Section listed below:7.1.6.4* Slip Resistance. Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel7.1.10.1* 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 emergencyThis 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 at the exit conference.

Through observation during the survey and documentation review, it was determined that the facility failed to meet the Emergency Lighting requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) Emergency lighting documentation was provided on the following dates. 01/2025, 12/2024, 11/2024, 10/2024, 09/2024, 08/2024, 07/2024, 06/2024. Additionally, one inspection page was provided, with a full calendar year listed. However, the year was not listed on the page. There were no inspection reports before 06/2024 available for review. Life Safety Code Section listed below: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 11/2 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 jurisdictionThis 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 at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Portable Fire Extinguishers requirements in accordance with NFPA 10. This STANDARD is not met, as evidenced by: 1) During the tour of the facility, many fire extinguishers were mounted too high above the finished floor. The facility shall audit all locations, however the following areas were specifically noted. Dining Room, Extinguisher near room 36,Life Safety Code Section listed below:NFPA 10:6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 smoke compartment. Deficient items were discussed with the administrator at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Corridor - Doors requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) The door to room 14 had a too-large gap and would not resist the passage of smoke. 2) The door to room 36 had the striker plate missing, which positively latches the door in place. Without this striker plate, the door could not resist the passage of smoke because the gap between the door and frame was too large. Life Safety Code Section listed below:19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 13/4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes19.3.6.3.5* 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. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 smoke compartment. Deficient items were discussed with the administrator at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the Utilities – Gas and Electric requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) The Laundry room had an electrical subpanel. When the subpanel was opened, blanks or breakers were missing. In one area, black electrical tape was used in lieu of a blank. 2) The laundry room water heater had the cover for all the electrical components removed, exposing the electrical wiring. 3) The shower room had a two-gang light switch, commonly known as a double light switch. There were also two common light switches or toggle light switches. The cover was for one toggle light switch and one rocker light switch. Because the light switch cover was not intended for this use, the metal parts of the light switch were exposed. 4) In the conference room, a plastic electrical cord ran from the room under the door into the space that used to be the bathroom. 5) Above the ceiling tile in the area where the smoke barrier separates the front and back corridors, there is a junction box without the cover, exposing electrical wiring. 6) On the conference room's exterior wall, there is an exterior wire mold containing electrical wiring. At the top of the wire mold, there is no junction box, and the wiring is exposed. 7) The gas dryer in the laundry room did not have a back cover. When this back cover was removed, the belts were completely exposed. Life Safety Code Sections Listed Below:19.5.1.1 Utilities shall comply with the provisions of Section 9.1.9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70: 422.4 Live Parts. Appliances shall have no live parts normally exposed to contact other than those parts functioning as open-resistance heating elements, such as the heating element of a toaster, which are necessarily exposedNFPA 70: 314.15 Damp or Wet Locations. In damp or wet locations, boxes, conduit bodies, and fittings shall be placed or equipped so as to prevent moisture from entering or accumulating within the box, conduit body, or fitting. Boxes, conduit bodies, and fittings installed in wet locations shall be listed for use in wet locations. NFPA 70: 314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminaire canopy, except where the installation complies with 410.24(B). NFPA 54: 9.1.1.2 Listed appliances, equipment, and accessories shall be installed in accordance with Chapter 9 and the manufacturers ' 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 at the exit conference.

Through observation during the survey and documentation review, it was determined that the facility failed to meet the HVAC requirements in accordance with NFPA 10. This STANDARD is not met, as evidenced by: 1) Through documentation review it was determined there was no damper inspection as the facility was under the impression that no fire dampers existed. 2) During the tour of the facility, it was determined that there is a fire damper in the laundry room. The facility shall audit the facility to determine if there are more fire dampers. Life Safety Code Sections Listed Below:NFPA 80: 19.4.1 Each damper shall be tested and inspected 1 year after installation. NFPA 80: 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. NFPA 80: 19.4.4 If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. NFPA 80: 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. NFPA 80: 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. NFPA 80: 19.4.10 All documentation shall be maintained and made available for review by the AHJ.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 smoke compartment. Deficient items were discussed with the administrator at the exit conference.

Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) The fire drill documentation consisted of the following dates and times. 12/31/2024 the documentation stated it was for the second shift, however no times were listed. The documentation did not comply with the requirements of the code, only a staff log sheet was provided. 12/29/2024 No shift or time as recorded on the documentation. The documentation did not comply with the requirements of the code, only a staff log sheet was provided. 10/30/2024 the documentation stated it was for the second shift, however no times were listed. The documentation did not comply with the requirements of the code, only a staff log sheet was provided. 10/28/2024 No shift or time as recorded on the documentation. The documentation did not comply with the requirements of the code, only a staff log sheet was provided. 09/04/2024 2nd shift, 5 AM08/29/2024 1st shift, 1 PM06/28/2024 1st shift, 11:30 AM06/07/2024 1st shift, 11:30AM05/09/2024 No shift or time. The documentation did not comply with the requirements of the code, only a staff log sheet was provided. 04/29/2024 2nd shift, 1AM04/12/2024 1st shift, 12.59 PM03/21/2024 1st shift, 1 PM02/21/2024 1st shift, 9AM01/29/2024 1st shift, 11AM12/20/2023 1st shift, 3pm2) It is unknown if any fire drills occurred on the 1st shift in the last quarter(October, November, December). 3) In the last quarter of 2024, for the second shift fire drills, the time is not listed, so the reliability is uncertain4) In the second quarter(April, May, June) of the 2024 the 06/28, and the 06/07 fire drills were too close to each other. Both occurred at 11:30 AM5) In the second quarter(April, May, June) of the 2024 the 05/09 fire drill has no shift or time listed. 6) No fire drills occurred for the second shift in the first quarter(January, February, March) of 2024. Life Safety Code Sections Listed Below:19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 4.7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 43 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate. 4.7.6* A written record of each drill shall be completed by the person responsible for conducting the drill and maintained in an approved manner. 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 at the exit conference.

Through observation during the survey and interview, it was determined that the facility failed to meet the Smoking Regulation requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) During the facility tour, while outside in the smoking area, there was no metal container with a self-closing cover to dump the ashes into. The administrator was interviewed on how the existing ashtrays were emptied, the administrator answered by saying the staff dumps them into the commercial garbage can. Life Safety Code Sections Listed Below:19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 exterior area. Deficient items were discussed with the administrator at the exit conference.

A recertification survey with complaint #CO36350, #CO37802 and #CO38553 was conducted on 12/16/24 to 12/19/24. Five deficiencies were cited.

An Emergency Preparedness survey was conducted from 12/16/24 to 12/19/24. No deficiencies were cited.

Based on interviews and record review, the facility failed to protect and keep residents safe from physical abuse for one (#37) of three residents reviewed for physical abuse out of 29 sample residents. Specifically, the facility failed to protect Resident #37 from physical abuse by a staff member. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy and procedure, revised September 2022, was received from the nursing home administrator (NHA) on 12/23/24 at 11:00 a.m. It revealed in pertinent part, "If resident abuse, neglect, exploitation, misappropriation or resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. "Upon receiving any allegation of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) were needed for the protection of the residents. "Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. "If the investigation reveals that the allegations of abuse were found, the employee(s) is terminated."II. Incident of physical abuseThe facility investigation of the incident involving Resident #37 revealed the following:On 11/16/24, an agency certified nurse aide (CNA) called the director of nursing (DON) and informed her she did not like how staff were treating residents and she would not be returning to the facility. The DON called the agency registered nurse (RN), who was working the night of 11/16/24 to get more information on the situation. The agency RN told the DON that the agency CNA was making negative remarks about the facility and the CNA was afraid Resident #37 would harm her. The agency RN told the DON Resident #37 had an increase in behaviors, along with exit seeking, during the evening and was placed on a one-to-one with a staff member. There were no further concerns reported to the DON regarding staff treating residents poorly. On 11/18/24 the nursing home administrator (NHA) and the DON reviewed security footage of the facility, per the usual routine, and identified an incident, on video surveillance, that occurred between Resident #37 and the agency RN. Video surveillance revealed the agency RN swinging her arm and knocking the resident's cup of water out of his hand and then she continued to push Resident #37, causing him to stumble backwards and lose his footing. The DON conducted an assessment on 11/18/24 of Resident #37 which concluded no injuries were noted to the resident. Resident #37 was interviewed but due to his level of cognition, he was unable to recall the event or provide information on what occurred. The facility identified Resident #37 was at his baseline for behaviors and exit seeking. The alleged assailant (agency RN) was interviewed on 11/18/24 by the DON and the NHA. The agency RN was shocked to hear she had pushed and hit Resident #37. The RN said the incident had only been a reaction and was not intentional. The facility investigation concluded that abuse did occur between the agency RN and Resident #37. The agency RN was not allowed to return to the facility and she was reported to the state board of nursing. The facility notified Resident #37's physician, the resident's representative and the local police department of the abuse. The incident was reported to the state occurrence website. An all staff meeting was conducted on 11/19/24 where the NHA reviewed appropriate interactions with residents and how they should be treated with dignity and respect. The NHA also reviewed the proper way to provide touch assistance. The NHA reviewed with all staff that it was never appropriate to put hands on a resident and if someone was experiencing behaviors that could not be redirected, it was best to give the resident some space and clear the area where the resident could de-escalate away from staff and other residents. III. Resident #37A. Resident statusResident #37, age greater than 65, was admitted 9/12/24. According to the December 2024 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances, chronic obstructive pulmonary disease (COPD - an abnormal exchange of oxygen in the lungs) and depression. The 9/20/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. He required partial assistance from staff for dressing. He required set up assistance for eating and personal hygiene. He was independent with transfers and ambulation. The assessment documented the resident did not reject care assistance and was not physically aggressive towards others. B. Resident representative interviewResident #37's representative was interviewed on 12/16/24 at 2:28 p.m. The representative said the facility had contacted her in November 2024 about an incident where Resident #37 and a staff member were pushing each other. She said the staff member had been terminated by the facility and Resident #37 had no injuries from the incident. C. Record reviewThe comprehensive care plan, initiated 9/18/24, documented Resident #37 had a behavior problem. He could be verbal with staff and other residents when sundowning. He could become agitated and physical with staff. He had a history of calling staff racial slurs during care or when they were attempting to redirect him. Interventions included allowing the resident to de-escalate in a calm area, providing activities of interest to the resident, explaining all care to the resident prior to initiating care to allow the resident to adjust to changes, offering snack preferences of chips and 7-Up, taking the resident for walks in the afternoon hours and monitoring the resident's hours of sleep. A behavior progress note, dated 11/16/24 at 6:06 a.m., documented Resident #37 was agitated and attempted to throw heavy objects at the nurse, along with exit-seeking and setting off the alarms on exit doors. A behavior note, dated 11/16/24 at 2:30 p.m., documented Resident #37 was exit-seeking. The resident was redirectable and given a task to complete. A behavior note, dated 11/16/24 at 10:10 p.m., documented Resident #37 had been exit-seeking with multiple attempts to redirect him. The resident was agitated and wanted to exit the alarmed doors. Resident #37 was mumbling as he approached the nurse who was at her medication cart preparing medications and the resident attempted to pour water on the nurse's head. The nurse put up her arm to stop the resident's advancement and the water from being poured. Resident #37 walked into the nurse's arm and stumbled off balance. The nurse documented the resident said he was sick of being told what to do. A CNA assisted the resident to his room in an attempt to calm him down with fewer people around to decrease the risk of negative interactions with other residents. Another resident was yelling at Resident #37 to not hit women. Resident #37 told the other resident to shut up. A CNA attempted to sit in Resident #37's room with him for safety but Resident #37 continued to exit-seek and became agitated. The CNA and the nurse attempted to change Resident #37's clothing due to it being soiled but he refused. Resident #37 became combative and attempted to trip and kick the nurse. A behavior note dated 11/17/24 at 12:00 a.m., documented direct care assignment of Resident #37 was directed to another licensed nurse with on- to-one CNA monitoring for safety and wellness. A behavior note, dated 11/17/24 a 5:32 p.m., documented Resident #37 had been on one-to-one supervision at all times to maintain safety and prevent exit-seeking actions. Resident #37 was provided with various chores and tasks to keep him occupied and reduce agitation. A behavior note, dated11/18/24 at 3:52 a.m., documented there was no physical aggression against staff noted. Resident #37 continued to exit-seek with increased agitation due to his inability to successfully and independently exit the facility. Resident #37 randomly sat and slept for short periods of time and then woke up to start pacing/exit seeking. IV. Staff interviewsThe DON was interviewed on 12/19/24 at 10:20a.m. She said abuse allegations were to be reported to the NHA immediately for further investigation. The DON said she received a call from an agency CNA on the night of 11/16/24. She said the agency CNA said she wanted to be removed from the schedule because she did not want to work in a place where the residents were not treated right. The DON said the agency CNA hung up on her before giving her any details regarding what she was referring to. The DON said she made several attempts to get in touch with the agency CNA after she hung up on her but the CNA did not answer her calls. The DON said once she was able to finally get ahold of the agency CNA again, she said the CNA told her she did not like how a resident was taken to their room by two staff members and then she stopped answering questions. The DON said the agency CNA would not give her any details about why she had concerns. The DON said after she talked to the agency CNA the second time, she called the facility and spoke with the RN assigned to the front unit to try to figure out why the CNA said she did not want to work at the facility. The DON said the agency RN informed her she was unable to find the agency CNA in the building and she was not aware of any concerns involving residents and staff. The DON said she interviewed all staff in the building via telephone on 11/16/24 and did not find any concerns with staff not treating residents correctly. She said she called the NHA to inform her of the concern and her findings on the night of the incident. The NHA was interviewed on 12/19/24 at 11:53 a.m. The NHA said she was the abuse coordinator for the facility and any reports of abuse were to be called to her attention 24-hours a day/seven days a week. She said the facility educated staff on what abuse was on hire and at all staff meetings. The NHA said she directed staff to report anything they might suspect was abuse. She said even if staff had doubts about whether abuse actually occurred, they should report it. The NHA said she was notified by the DON on 11/16/24 about an agency staff CNA who called and said she would not be returning to the facility due to how a resident was treated. The NHA said the DON interviewed all staff members, via telephone, who were working in the facility on 11/16/24 about concerns voiced by the agency CNA. The NHA said none of the staff members reported any concerns to the DON on the night of 11/16/24. The NHA said the agency RN completed her scheduled shifts on 11/16/24 and 11/17/24 because the initial interviews conducted by the DON on 11/16/24 did not lead the facility to believe abuse had occurred, as none of the staff interviewed voiced any concerns.. The NHA said when she came into the facility on the following Monday (11/18/24), she reviewed the video surveillance of the facility from the weekend, as was her usual practice. The NHA said when she was going through the surveillance footage from the weekend, she saw an incident between Resident #37 and the agency RN the DON had spoken to on the night of 11/16/24. The NHA said the video footage revealed that Resident #37 walked up to the agency RN from behind with a cup of water and when the RN turned around, she swatted the cup out of the resident's hand. The NHA said the footage further revealed the agency RN pushed the resident backwards with one hand. The NHA said the video had voice recording and the agency RN was heard yelling "stop, I didn't do anything to you." The NHA said Resident #37 was observed stumbling backwards and losing his balance but the NHA said the resident did not fall. The NHA said, after viewing the video footage and seeing what occurred between Resident #37 and the agency RN, she began an investigation into the incident. She said the facility attempted to interview Resident #37 about the incident, but she said based on his cognitive status, he was unable to recall the incident. She said the DON conducted a skin assessment on the resident and no injuries were noted. The NHA said she substantiated that abuse had occurred based on the video footage. The NHA said the physician, responsible party and the police were all notified of the occurrence on 11/18/24. The NHA said she reported the incident to the State Agency and the agency RN was reported to the agency company she worked for and to the state board of nursing. The NHA said the agency RN had been offered a position in the facility full-time prior to the incident, but the offer had been rescinded due to the abuse observed in the video surveillance. The NHA said the facility verified that all agency staff received education for abuse and dementia training from their respective agencies prior to working in the facility.

Based on observations, record review and interviews, the facility failed to ensure that its medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 6.45%, which was two errors out of 31 opportunities for error. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed., E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment."Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication."According to the Instructions for use Humalin R KwikPen, retrieved on 11/23/24 from: https://pi.lilly.com/ca/humulin-n-r-ca-ifu-kp.pdf It revealed in pertinent "Priming your pen. Prime before injections. Priming your Pen means removing the air from the needle and cartridge that may collect during normal use and ensure the pen is working correctly. If you do not prime the pen before injections, you may get too much or too little insulin."According to the How to Use Voltaren Gel instructions, retrieved on 12/23/24 from: https://www.voltarengel.com/arthritis-pain-gel/ It reveled in pertinent part "Dosage: using the dosing care, apply the following amounts: Upper body areas (hand, wrist, elbow: 2.25 inches. Lower body areas (foot ankle, knee): 4.5 inches"II. Facility policy and procedureThe Administering Medications policy and procedure, revised April 2019, was received from the nursing home administrator (NHA) on 12/19/24 at 1:29 p.m. It revealed in pertinent part, "Medications are administered in a safe and timely manner, and as prescribed."The individual administering medications checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medications."III. ObservationsOn 12/17/24 at 11:40 a.m. registered nurse (RN) #1 was administering medications for Resident #3. The medication ordered was Humalin R U-500 Kwik pen 500 units/milliliter (ml) inject 125 units subcutaneously before meals for diabetes. RN #1 collected the Humalin R pen from the medication cart, applied a new needle to the tip and dialed the insulin pen to 125 units. RN #1 then identified Resident #3, applied gloves, cleansed the site with an alcohol swab and administered the injection via pen into the resident's right lower abdomen. -RN #1 failed to prime the insulin pen for the correct dose of medications ( see professional reference above). On 12/19/24 at 8:27 a.m. RN #1 was administering medications for Resident #10. The medication ordered was Volataren arthritis pain external gel one percent, apply to the right hip topically three times a day for osteoarthritis. RN #1 obtained a tube of Voltaren gel one percent from the treatment cart. He opened the tube and poured out about a quarter in diameter gel directly into a medication cup. RN #1 then identified Resident #10 applied gloves and applied the gel to the resident's right hip. -RN #1 failed to identify the medication order did not have a dose indicated (see professional reference above) in order to administer the correct dose to the resident. IV. Staff interviewsRN #1 was interviewed on 12/17/24 at 12:41 p.m. RN #1 said insulin vials needed to be cleansed with an alcohol swab prior to inserting a needle to draw up the insulin. RN #1 was not aware he needed to cleanse the top of the insulin pen prior to applying the needle. RN #1 said he was did not know he needed to prime an insulin pen before dialing to the ordered dose. RN #1 said priming would waste the insulin. RN #1 said he would need to find out what the facility protocol on insulin pens was. Licensed practical nurse (LPN) #1 was interviewed on 11/17/24 at 12:56 p.m. LPN #1 said insulin pens did not need to be primed after applying a new needle. The director of nursing (DON) was interviewed on 12/18/24 at 3:09 p.m. The DON said insulin pens should be cleaned prior to applying the needle and the pen should be primed prior to dialing up the dose. The DON said priming was important to ensure the correct dose was administered, not priming could lead to too much or too little insulin being administered. RN #1 was interviewed again on 12/19/24 at 9:40 a.m. RN #1 said he administered the Voltaren gel as ordered for Resident #10. He said after reviewing the Voltaren gel order he was able to identify the order was missing a dose. He said he was not aware he needed to use the dosing card inside the Voltaren gel box. RN #1 said he would call the physician immediately to get the dose added to the order. The DON was interviewed again on 12/19/24 at 10:20 a.m. The DON said an order should include the right person, medication, dose, frequency and route. The DON said if the order was missing one of the five rights it was to be corrected immediately to prevent medication error. The DON said her charting system did not allow for the dose to be put in and she would have to figure out how it can be added. The DON said Voltaren gel had a dosing card that should be used to ensure the correct dose is being administered.

Based on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for one resident (#3) out of 29 sample residents. Specifically the facility failed to ensure insulin pens were primed prior to medication administration for Residents #3. Cross-reference F759 failure to ensure the medication error rate was less than five percent (%). Findings include:I. Professional referenceAccording to the Instructions for use Humalin R KwikPen, retrieved 12/26/24 from: https://pi.lilly.com/ca/humulin-n-r-ca-ifu-kp.pdf It revealed in pertinent "Priming your pen. Prime before injections. Priming your Pen means removing the air from the needle and cartridge that may collect during normal use and ensure the pen is working correctly. If you do not prime the pen before injections, you may get too much or too little insulin."II. Facility policy and procedureThe Administering medications policy and procedure, revised April 2019, was received from the nursing home administrator (NHA) on 12/19/24 at 1:29 p.m. It revealed in pertinent part, "Medications were administered in a safe and timely manner, and as prescribed."The individual administering medications checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medications."III. Resident #3A. Resident statusResident #3, age greater than 65, admitted on 2/22/16. According to the December 2024 computerized physician orders (CPO) diagnoses included type one diabetes (abnormal glucose control), obesity and paranoid schizophrenia (abnormal thinking process). The 11/22/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. He required set up assistance with personal hygiene. He was independent for eating, dressing, toileting and transfers. The MDS assessment revealed the resident received insulin injections for the past seven days. B. Physician's ordersThe December 2024 CPO documented a physician's order for Resident #3. The order read: "Humalin R U-500 kwikPen, Inject 125 units subcutaneously before meals for diabetes."C. Observations On 12/17/24 at 11:40 a.m. registered nurse (RN) #1 was administering medications for Resident #3. The medication ordered was Humalin R U-500 Kwik pen 500 units/milliliter (ml) inject 125 units subcutaneously before meals for diabetes. RN #1 collected the Humalin R pen from the medication cart, applied a new needle to the tip and dialed the insulin pen to 125 units. RN #1 then identified Resident #3, applied gloves, cleansed the site with an alcohol swab and administered the injection via pen into the resident's right lower abdomen. -RN #1 failed to prime the insulin pen for the correct dose of medications (see professional reference above). III. Staff interviewsRN #1 was interviewed on 12/17/24 at 12:41 p.m. RN #1 said insulin vials needed to be cleansed with an alcohol swab prior to inserting a needle to draw up the insulin. RN #1 said he was not aware he needed to cleanse the top of the insulin pen prior to applying the needle. RN #1 said he did not know he needed to prime an insulin pen before dialing to the ordered dose. RN #1 said priming would waste the insulin. RN #1 said he would need to find out what the facility protocol on insulin pens was. Licensed practical nurse (LPN) #1 was interviewed on 11/17/24 at 12:56 p.m. LPN #1 said insulin pens did not need to be primed after applying a new needle. The director of nursing (DON) was interviewed on 12/18/24 at 3:09 p.m. The DON said insulin pens should be cleaned prior to applying the needle and the pen should be primed prior to dialing up the dose. The DON said priming was important to ensure the correct dose was administered, not priming could lead to too much or too little insulin being administered.

Based on observations, record review and interviews, the facility failed to ensure food items were stored, prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to have a system in place to monitor the internal water temperature and concentration (parts per million-ppm) of hypochlorite of the dish machine in the main kitchen to ensure tableware, drinkware and cookware were effectively sanitized. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised March 2024, retrieved on 12/26/24, read in pertinent part:"A test kit or other device that accurately measures the concentration in MG/L (milligrams per liter) of sanitizing solutions shall be provided." (page 125)"A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times shall meet the criteria specified in accordance with the EPA- registered label use instructions ...""A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart:The concentration range minimum temperature chart indicated if the MG/L was 25 to 49 and the PH (potential of hydrogen) was 10 or less or the PH was eight or less the temperature of the water needed to be 120F. If the MG/L was 50 to 99 and the PH was 10 or less or eight or less the water needed to be 100F. If the MG/L was 100 and the PH was 10 or less or eight or less the water needed to be 55F."The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120°F. (page 129 to 130)II. Facility policy and procedureThe Dishwashing Machine Use policy and procedure, revised March 2010, was received from the nursing home administrator (NHA) on 12/19/24 at 1:29 p.m. It revealed in pertinent part, "Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation ..."Dishwashing machine chemical sanitizer concentrations and contact times will be as follows:If the solution is chlorine the minimum concentration is 50 to 100 ppm with a contact time of 10 seconds. If the solution is iodine the minimum concentration is 12.5 ppm with a contact time of 30 seconds. If the solution is quaternary ammonium the minimum concentration is 150 to 200 ppm and the contact time is per the manufacturer's instructions."A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution (measured as parts-per-million [PPM] or mL/L) after filling the dishwashing machine and once a week thereafter. Concentrations will be recorded in a facility approved log. "Corrective action will be taken immediately if sanitizer concentrations are too low. "The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during the dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. "The supervisor will check the calibration of the gauge weekly by running a secondary thermometer through the machine to compare temperatures; or using commercial temperature test strips following manufacturer's instructions. "If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machines immediately until temperatures or ppm are adjusted."III. Observations and staff interviewsOn 12/16/24 at 9:08 a.m. the kitchen dish machine was in use after the breakfast meal. The dietary manager (DM) said the dish machine used chemicals for sanitization. There were no test strips available to test the chemical solution. The DM said they ran out of test strips two or three days prior. The DM said the staff were using the temperature on the machine for monitoring the effectiveness of disinfecting until the test strips were delivered. The dish machine was 130F. On 12/18/24 at 1:25 p.m. the dishwasher was in use. The DM said he still had not received test strips to check the dishwashing machines chemical use. The dish washer temperature was 130F.Dietary aide (DA) #1 was interviewed on 12/18/24 at 1:30 p.m. She said she checked the temperature on the dish machine once per meal. DA #1 said she recorded the temperature on the log sheet. The November 2024 (11/1/24 to 11/30/24) and December 2024 (12/1/24 to 12/19/24) machine log sheets were reviewed with DA #1 and she confirmed there were days that were missing temperature monitoring of the dish machine. DA #1 said she did not know what was an acceptable temperature. DA #1 said she had never tested the dishwasher chemicals. IV. Record reviewThe dishwasher temperature log from 11/28/24 to 12/19/24 was reviewed on 12/19/24 at 1:58 p.m. it documented the following: -On 11/28/24 there was not a temperature logged for the dinner service;-From 11/30/24 to 12/5/24 there were no temperatures logged;-On 12/7/27 there were no temperatures logged for the lunch or dinner service;-On 12/8/24 the temperature was 115F for breakfast service with no corrective action documented;-From 12/9/24 to 12/12/24 there were no temperatures logged;-On 12/13/24 there were no temperatures logged for the lunch or dinner service;-On 12/14/24 the temperature was 110F for breakfast and 100F for lunch. There was no temperature logged for dinner services.-On 12/15/24 the temperature was 100F for breakfast service.-On 12/16/24 the temperature was 110F for breakfast and there was no temperature logged for dinner service. -On 12/17/24 there was no temperature logged for dinner service.-The dishwasher machine log had no place to document the ppm was being monitored. The dishwasher log failed to consistently document the temperature of the dishwasher, along with no testing of the ppm for chemical sanitization. The log documented several days with temperatures out of range (see professional reference above). V. Additional staff interviews DA #2 was interviewed on 12/18/24 at 1:51 p.m. He said from time to time he would assist with washing dishes. DA #2 said the temperature on the dishwashing machine should be between 35 and 45 degrees fahrenheit. DA #2 said they were to use the dip sticks in the dishwasher to ensure the proper amount of chemical was being used for disinfecting purposes. DA #2 said the dip stick should be a green to dark green color to be in the correct range. DA #2 said he did not know the ppm levels the dishwasher should read during testing. The infection preventionist (IP) was interviewed on 12/19/24 at 10:27 a.m. The IP said the dishwasher chemicals were dispensed from a machine. The IP said she did not know what the chemical concentration needed to be to ensure proper sanitization. The IP said the dish machine was a low temperature dishwasher that used chemicals to sanitize the dishes. The IP said she needed to check with the DM for the correct intervals the dishwasher should be checked, but she believed it was every four hours. The IP said it was important for the dish machine to be functioning appropriately to ensure proper sanitization of dishes to prevent spread of infection. The DM was interviewed on 12/19/24 at 1:16 p.m. He said he had been educated to ensure the dishwasher temperature was at least 120F and the ppm should be between 50 and 100 for chlorine. The DM said he would call the chemical servicing company if they discovered the chemical dispensing was inaccurate based on testing strips. The DM said if the dishwasher was not working the dietary staff would washing dishes manually in the sink and the ppm would be checked of the sanitizer in the sink to ensure it was effectively sanitizing. The DM said he had testing strips the whole time during the survey. The DM said he did not know he could use the same testing strips he used on his sanitization buckets. The DM said the staff were responsible for documenting the ppm and the temperatures for all areas that chemicals were used in the kitchen. The DM said the manager on duty was responsible for checking the logs on the weekends or when he was not in the facility to ensure they were filled out daily. The DM said he was not sure why the logs were not being completed or how the log sheet did not have a section for ppm to be recorded. The DM said he would be completing education to the staff. He said he would change the log sheets immediately to ensure the temperatures and ppm could be recorded appropriately. The DM said he tested the ppm on the dishmachine once he learned he could use the same strips and it was above 50 ppm.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touched areas (call lights, door handles and handrails);-Ensure housekeeping staff used the correct surface disinfectant products; -Ensure enhanced barrier precautions (EBP) were in place for a resident with a stage IV pressure injury prior to wound care; and,-Ensure washing machine temperatures were checked daily and lint traps were emptied timely. Findings include:I. Housekeeping A. Professional referenceAssadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 12/21/24 from https.//pubmed.ncbi.nlm.nih.gov. It revealed in pertinent part,"High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment." The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 12/21/24 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/preent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part,"High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs."Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions."B. Facility policy and procedureThe Daily Room Cleaning policy, undated, was provided by the nursing home administrator (NHA) on 12/19/24 at 1:19 p.m. It read in pertinent part, "Throughout the cleaning process, you must be thorough as germs are everywhere. In corners, small openings, grooves, and the underside of objects. "Dip the cleaning cloth into the disinfectant and hand wring. Wipe the headboard, the bed controls and the foot board. Disinfect the night stand top, the sides, the front, the back and the legs. Wipe the telephone paying close attention to the receiver. Clean the over bed table and clean it thoroughly, working from the upper surfaces to the lower surfaces. Wipe clean the pedestal, base and the casters."Disinfect the toilet bowls, flush before cleaning. Apply toilet bowl cleaner and disinfectant to the inside of the toilet. Clean the rim, spray the outside and bottom surfaces with disinfectant solution and wipe and spray the toilet seat with the disinfectant."Spray a small amount of cleaner in the sink and rub the cleaner around the top and inside of the sink. Wipe the sink and the top dry. Dampen a cloth in disinfectant and wipe the counter top, being careful to clean under personal items left by the resident. Clean under the personal items left by the resident. Clean under the items and place them back in a neat arrangement. Clean the counter front, inside sink doors, the piping, and all exposed surfaces of the entire unit. Use pre-measured disinfectant floor cleaning chemicals for mopping. "Before leaving the room, inspect the room according to the checklist and to make sure all required cleaning tasks were performed."C. ObservationsDuring a continuous observation on 12/18/24 at 10:06 a.m. housekeeper (HSK) #1 was observed cleaning room #11, room #13 and room #14. HSK #1 pushed the cleaning cart to the door way of room #11. She donned (put on ) gloves and removed a disinfectant spray bottle and the toilet brush from the cart. She entered room #11's bathroom. She sprayed the inside of the toilet bowl and scrubbed it with the toilet brush. She placed the toilet brush back into the cart and removed her gloves. She used hand sanitizer and put on clean gloves. She removed a small container of a soap solution and a scrubbing pad. She washed the inside of the sink. She placed the container with the scrub pad back into the cart. She removed the broom and swept the room. She placed the broom and dust pan back onto the cart and removed a green rag. She placed the green rag on the sink and splashed water onto the mirror. She used a paper towel from the dispenser to wash the mirror. She turned on the sink and wet the green rag. She wiped out the inside of the sink, the top of the sink and the faucet. -HSK #1 did not use a disinfectant while cleaning the sink. HSK #1 washed her hands and donned clean gloves and removed the disinfectant spray bottle and a green rag from the cart. She sprayed the toilet. She used the green rag to wipe the seat of the toilet, the rim, the toilet seat a second time, the back of the seat, the side of the toilet, the front of the toilet tank and the top of the tank. She sprayed the two grab bars, on each side of the toilet, with the disinfectant spray and used the same rag to clean the grab bars. She placed the spray bottle and rag back onto the cart. She removed her gloves, used hand sanitizer, and donned clean gloves. She removed a mop pad from the water bucket and sprayed it with a cleaner. She dropped the mop pad on the floor and placed the mop handle on top. She mopped the room first and then the bathroom. She pushed the cleaning cart to room #13.-HSK #1 failed to use the correct cleaning techniques to clean the toilet and the grab bars. -HSK #1 said there was no disinfectant in the mop pad bucket and it only contained plain water.-HSK #1 did not disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HSK #1 used hand sanitizer and donned gloves and entered room #13. She removed the container of a soap solution and a scrubbing pad and washed the inside of the sink. She returned the container to the cart and removed the disinfectant spray. She sprayed the leather recliner and used a green rag to wipe it down. She placed the soiled rag on the cart. She removed a clean green rag from the cart and walked to the sink. She used her gloved hand to splash water onto the mirror. She wiped it dry with a paper towel. She sprayed disinfectant onto the rag and wiped the top of both of the night stands. She placed the soiled rag on the cart and removed the broom. She then swept the room. She placed the broom back on the cart and removed a mop pad from the water bucket. She sprayed the mop pad with cleaner and mopped the bedroom floor. The bathroom was shared with room #11. She pushed the cleaning cart to room #14.-HSK #1 said there was no disinfectant in the mop pad bucket and it only contained plain water.-HSK #1 did not disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HSK #1 used hand sanitizer, donned gloves and entered room #14. She removed the toilet brush from the cart and proceeded to the bathroom. The toilet seat had feces on it and there was feces in the toilet bowl. She did not flush the toilet. She used the toilet brush to clean the inside of the toilet bowl and then used the brush to clean the feces off the seat. She placed the toilet brush back onto the cart and removed her gloves. She used hand sanitizer and donned clean gloves. She removed the broom from the cart and began sweeping the room. She moved the night stand and swept behind it. A comb and tube of toothpaste was in the debris. She picked up the items and shook them off. She placed both items back onto the night stand. There was still debris in the comb. She swept the rest of the debris to the doorway and picked it up with the dust pan. She removed the disinfectant and a green rag from the cart. She wet the rag at the sink and proceeded to the bathroom. She sprayed the toilet with disinfectant and used the rag to wipe it. She first wiped the tank, the seat, under the seat, the rim, the side of the toilet and the sides. She sprayed the window sill and used a clean rag to wipe it. She returned the spray bottle and the soiled rags to the cart. She removed her gloves, used hand sanitizer and donned clean gloves. She removed a mop pad from the water bucket and sprayed it with a cleaner. She dropped the mop pad on the floor and placed the mop handle on top. She mopped the room and emptied the trash. She removed the soiled mop pad and replaced it with a clean mop pad from the water bucket. She did not spray the second mop pad with a cleaner. She then mopped the bathroom floor. She placed the mop pad and handle back onto the cart. She removed a small container of a soap solution and a scrubbing pad. She washed the inside of the sink. She again splashed water onto the sink top and mirror and wiped them dry with a paper towel. She placed a wet floor sign at the door entrance and exited the room. -HSK #1 failed to use the toilet brush only on the inside of the toilet and use a disinfectant on the toilet. She failed to discard the comb and tooth paste into the trash and placed them back on the night stand to be used. She failed to use a disinfectant when mopping the bathroom floor and failed to use a disinfectant while cleaning the sink. She failed to clean horizontal surfaces and high touch surfaces. D. Staff interviewsHSK #1 was interviewed on 12/18/24 at 10:37 a.m. HSK #1 said she used the container of dish soap and water, with the scrub pad, to clean the sink in all the resident's rooms. She said she changed the scrub pad once a week and used the dish soap because she felt it was the best product to disinfect with. She said the toilet brush should only be used for the inside of the toilet bowl, but since there was dried feces on the seat she had to use the toilet brush to clean the seat. She said the toilet should have been cleaned from top to bottom. She said she used the toilet brush to clean the seat, because she did not have another rag. She said high touch areas, such as door knobs, grab bars, sink handles and call lights should be cleaned daily. She said there was only water in the mop bucket, but she sprayed the mop with a cleaner to rid the room of odors. The housekeeping and laundry manager (HLM) was interviewed on 12/18/24 at 11:09 a.m. The HLM said a multipurpose cleaner should have been used for the cleaning of the floors. He said there was a chemical dispensing system in the janitor closet. He said when the HSK filled the mop bucket they should have pushed the button on the dispenser to add the cleaner to the water. He said the cleaner spray was only used to give the room a clean smell and did not disinfect. He said the toilet brush should never be used outside of the toilet bowl. He said the toilet should be cleaned with a disinfectant and wiped with a clean rag from top to bottom. He said high touch surfaces should be disinfected daily as well as the sink and any frequently touched surfaces. He said HSK #1 should not have cleaned the grab bars after the toilet with the same rag. He said the toilet should always be cleaned last. He said HSK #1 should have thrown the comb and tooth paste in the trash so it could not be used. He said he would reeducate HSK #1 on the room cleaning process and procedures. The infection preventionist (IP) was interviewed on 12/19/24 at 10:47 a.m. The IP said a resident's room should be cleaned from top to bottom and cleanest to dirtiest. She said the bathroom should always be cleaned last. She said the grab bars should have been cleaned prior to the toilet. She said the toilet should be cleaned from top to bottom and the toilet bowl last. She said the toilet brush should only be used inside the toilet. She said a disinfectant should have been used to clean the sink, high touch surfaces and when mopping the floor. She said if items were on the floor, they should have been thrown away. She said she would immediately reeducate the housekeeping staff on the correct room cleaning process and the use of the correct cleaning chemicals. II. Enhanced barrier precautionsA. Facility policy and procedureThe Enhanced Barrier Precautions policy, revised March 2024, was provided by the NHA on 12/19/24 at 1:19 p.m. It read in pertinent part, "Enhanced barrier precautions were utilized to reduce the transmission of multi-drug resistant organisms (MRDOs) to residents. Gown and glove use in addition to standard precautions should be used during high contact resident care activities when contact precautions do not apply."High-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing, transferring, changing linen, changing brief or toileting, device care and wound care."EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MRDO colonization. Wounds generally include chronic wounds such as pressure ulcers, diabetic foot ulcers, venous stasis ulcers and unhealed surgical wounds. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk."Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside of the resident rooms. Residents, families and visitors are notified of the implementation of EBPs throughout the facility."B. ObservationsOn 12/18/24 at 12:19 p.m. Resident #35 was laying in bed waiting for the wound physician to perform wound care. The wound care physician and registered nurse (RN) #1 used hand sanitizer and donned gloves. They entered Resident #35's room and began her wound care. -The facility failed to identify the need for Resident #35 to be placed on EBPs for her chronic stage IV pressure injury. C. Staff interviewsRN #1 was interviewed on 12/18/24 at 1:43 p.m. RN #1 said he was not sure what enhanced barrier precautions were or when they should be put into place. The director of nursing (DON) was interviewed on 12/18/24 at 1:44 p.m. The DON said there were no residents in the facility, at the time of the survey, that required EBPs. She said she would check to see if any residents needed to be on EBP. When she returned, she said Resident #35 should have been placed on EBPs and was not sure why she was not. She said she would immediately get a physician's order and place Resident #35 on EBPs. She said when a resident was on EBP the staff needed to wear a gown, gloves and mask prior to completing wound care. III. Laundry A. Facility policy and procedureThe Soiled Laundry and Bedding policy, revised September 2022, was provided by the nursing home administrator (NHA) on 12/19/24 at 1:19 p.m. It read in pertinent part: "Laundry equipment (washing machines and dryers) are used and maintained according to the manufacturer's instructions for use to prevent microbial contamination of the system. Laundry processed in hot water temperatures is 160 degrees F (fahrenheit) for 25 minutes. Laundry that is not hot water compatible, low temperature washing at 71 degrees to 77 degrees F (22-25 degrees celcius) plus chlorine or oxygen-activated bleach can reduce microbial contamination."The Cleaning Lint in Laundry policy, undated, was provided by the NHA on 12/19/24 at 1:19 p.m. It read in pertinent part: "The policy statement was to maintain a safe, efficient, and sanitary laundry environment, lint must be regularly cleaned from laundry machines, lint traps, and surrounding areas. THis reduces the risk of fire, ensures proper machine function and maintains hygiene standards in the facility. "The purpose was to establish a consistent procedure for cleaning lint in laundry facilities to promote safety, improve equipment performance and ensure compliance with applicable regulations."Remove the lint trap from the machine carefully after every load of laundry. Use a lint brush or hand to remove accumulated lint. Place the lint into a designated trash receptacle. Inspect the lint trap for tears or damage. Report any issues to the supervisor immediately. Maintain a log of daily, weekly, and monthly lint cleaning activities. Note any issues, repairs, or maintenance required in the log."B. ObservationsThe laundry room was observed on 12/18/24 at 2:34 p.m. There were two washing machines. C. Record reviewA request was made for the temperature log for the washing machines. The facility was unable to provide a temperature log for the two washing machines. D. Staff interviewsThe HLM was interviewed on 12/18/24 at 2:34 p.m. He said he did not know he needed to check the temperature on the washing machines. The regional director of plant operations (RDPO) was interviewed on 12/18/24 at 10:47 a.m. He said the washing machine temperatures should reach 160F and tested daily with a thermometer to disinfect the laundry properly. The IP was interviewed on 12/19/24 at 10:47 a.m. The IP said she did not know how often the washing machine temperatures should be checked or what the temperature should be at.

A complaint survey, prompted by #CO34989 and Incident #35505 was completed on 4/25/24 to 5/1/24. One deficiency was cited.

Based on observations, interviews, and record review, the facility failed to ensure two (#1 and #2) out of five sample residents at risk for elopement, received adequate supervision and facility assistive devices to prevent elopement. Specifically, the facility failed to provide Resident #1 and Resident #2 the supervision necessary to prevent elopements. These facility failures created a situation with serious harm and a situation with the likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1, diagnosed with schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), unsteadiness on feet, restlessness and agitation and need for supervision, eloped from the facility on 12/24/23 at approximately 10:11 p.m. when he exited the facility through an alarmed dining room door and an outside gate which was unlocked. Facility staff were unaware Resident #1 was missing until agency certified nurse aide (ACNA) #1 returned to the facility from break at approximately 10:44 p.m. (33 minutes later) and observed the resident seated on the ground in the snow and stuck in an orange construction site fence (a safety barrier, lightweight fence) that separated the facility property from nearby construction. Resident #1 was brought back into the facility by staff and assessed by registered nurse (RN) #1. RN #1 encountered difficulties with obtaining the resident's vital signs and the resident was transported to the hospital for further evaluation shortly thereafter where the resident was diagnosed with right lower extremity frostbite. Resident #1 did not return to the facility per family request. The facility began investigating the incident on 12/27/24 (three days after the resident eloped) and determined Resident #1 eloped from the facility due to the staff's failure to respond to the sound of the dining room door alarm. The facility responded by providing education to the facility staff, beginning on 12/27/24, on resident elopement and what to do in the event a door alarm went off. The facility created a binder for all agency staff to read before their shift to learn what to do in the event a door alarm went off. The facility began monitoring the elopement interventions in the quality assurance and performance improvement (QAPI) meetings beginning on 1/11/24 and planned to monitor the process for three months or longer as needed. The education regarding elopement interventions and responding to door alarms proved to be ineffective as another resident elopement occurred on 2/2/24. Resident #2, diagnosed with paranoid schizophrenia (a mental disorder characterized by recurrent episodes of psychosis that are correlated with a general misperception of reality) and dementia, eloped from the facility on 2/2/24 at 9:48 p.m. when he exited the facility through the same alarmed dining room door and unlocked outside gate. At 10:20 p.m. (32 minutes later) the local police department called the facility to ask if the facility was missing a resident. Facility staff did a search of all residents and discovered Resident #2 was missing from the facility. At 10:30 p.m. the facility nurse called the police back and informed them Resident #2 was missing. The police informed the facility Resident #2 was found at a busy intersection approximately one tenth of a mile from the facility and had been taken to a local hospital for an evaluation. Resident #2 returned to the facility from the hospital on 2/3/24 at 1:25 a.m. with no noted injuries. Findings include:Observations, interviews, and record review confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/25/24 to 5/1/24, resulting in the deficiency being cited as past noncompliance with a correction date of 2/7/24. I. Situation of serious harmThe facility failed to ensure facility staff were aware of the proper procedures to respond timely to door alarms and how to reset the alarm for a door once an alarm had been triggered. This resulted in Resident #1 eloping from the facility on 12/24/23 and sustaining frostbite to his right lower extremity. Following the elopement incident with Resident #1 on 12/24/23, the facility failed to put effective interventions and systems into place to ensure further resident elopements did not occur. This resulted in Resident #2 eloping from the facility on 2/2/24 and being found by the local police department at a busy intersection approximately one tenth of a mile from the facility and taken to a local hospital for an evaluation. II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #2's elopement incident on 2/2/24 was provided by the nursing home administrator (NHA) on 4/25/24 at 2:00 p.m. A. Immediate actionResident #2's care plan was updated on 2/5/24 to include the following interventions:-Provide activities to attempt giving the resident meaningful activities;-Facility to add a chirping alarm to dining room doors; and,-Nursing to conduct frequent checks for resident's whereabouts. B. Identification of others affectedThe facility determined, due to the facility's population of residents with dementia, every resident was at risk for eloping from the facility. C. Systemic changes-On 2/3/24 the facility ordered new door alarms. The new alarm system had no automatic shut off and the alarm continued to sound until it was turned off by the facility staff and rearmed with a key. -On 2/3/24 the facility ordered items to rebuild the entire egress area (where the outside gate was opened). The ordered items included black aluminum fence panels, fast setting concrete mix, a new gate door, door hardware for installation, and a battery operated powered door mounted weatherized exit alarm.-On 2/3/24 facility staff were educated on how to turn the current alarms off until the new door alarms were installed.-On 2/3/24 the staffing agency was notified via text of the elopement binder with directions of how to turn the current alarms off which was to be read by all agency staff before each person worked in the facility.-On 2/5/24 visual aide note cards were added to the doors about how the keys were to turn to reset the alarms on the doors.-On 2/7/24 the new door alarms were installed and staff education of how to work the alarms began.-On 2/7/24, weekly documentation of safety checks on the door alarms was started by the plant operations director (POD).-On 2/29/24, the outside gate improvement project was completed. Weekly checks of the outside gate area were started.-On 2/7/24 the new door alarm system was installed which removed the immediacy of the deficient practice. The outdoor gate improvement project, which was completed on 12/29/24, was an additional security measure put in place by the facility, however, it was not the main security issue, therefore the correction date for the deficient practice was 2/7/24. D. Monitoring The facility would monitor the elopement situation and the weekly safety check documentation in the monthly QAPI meetings. Observations, interviews and record review during the complaint investigation from 4/25/24 to 5/1/24 revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained corrections were in place. III. Facility Policy and proceduresThe Elopement Management System policy, March 2023, was provided by the NHA on 4/25/24 at 2:50 p.m. It revealed in pertinent part,"Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident with adequate supervision, activity/functional programs as appropriate and safety interventions to minimize elopement risk. Signaling devices may be used, if available, and determined to be an appropriate intervention."The Interdisciplinary Team (IDT) evaluates each resident to identify elopement risk. A Care Plan is developed and implemented based on this evaluation, with ongoing review. The Administrator and Director of Nursing are responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk assessment, treatment, evaluation, and monitoring of exit-seeking behavior."Unsafe Wandering or Elopement"According to the Centers for Medicare & Medicaid Services,"Wandering is random or repetitive locomotion. This movement may be goal-directed (the person appears to be searching for something such as an exit) or may be non-goal-directed or aimless. Non-goal-directed wandering requires a response in a manner that addresses both safety issues and an evaluation to identify root causes to the degree possible. Moving about the center aimlessly may indicate that the resident is frustrated, anxious, bored, hungry, or depressed. Unsafe wandering and elopement may be associated with falls and related injuries. Unsafe wandering may occur when the resident at risk enters an area that is physically hazardous or that contains potential safety hazards (chemicals, tools and equipment)."While alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision."The Maintenance Director or designee will complete preventive maintenance for door monitor testing, door range testing, function tester maintenance and elopement drills."Care Plan interventions are individualized to the resident and are based on the assessed risk of elopement."IV. Resident #1A. Resident statusResident #1, age over 75, was admitted on 10/12/23 and readmitted on 12/6/23. According to the October 2023 computerized physician orders (CPO), diagnoses included schizoaffective disorder, cerebral infarction (stroke), unsteadiness on feet, adult failure to thrive, vascular dementia, hypertension (high blood pressure), need for continuous supervision and restlessness and agitation. The 10/17/23 minimum data set (MDS) assessment revealed the resident had severely impaired cognitive skills for daily decision-making and had disorganized thinking. He required maximum assistance with toileting, showering, upper and lower body dressing, and putting on and off footwear. He was always incontinent of bowel and bladder. He used a wheelchair. He needed supervision or touch assistance to walk 150 ft. (feet). B. Record reviewThe comprehensive care plan initiated, on 10/16/23 and revised on 11/3/23, revealed Resident #1 was at a high risk for falls related to confusion, gait and balance problems, poor communication and comprehension. The resident was unaware of safety needs and wandered. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed and responding promptly to all of the resident's requests for assistance. The elopement evaluation, dated 12/25/23 revealed the resident ambulated with or without the use of an assistive device or wheelchair. The resident had a history of elopement or attempted elopement while at home. The resident had a history of elopement or attempted to leave the facility without informing staff. The resident had expressed a desire to go home, packed belongings to go home or stayed near an exit door. The resident wandered and his wandering was likely to affect the safety of himself or others. The nursing progress note related to the elopement incident on 12/24/23, documented on 12/25/23 by RN #1 revealed RN #1 piled blankets on Resident #1 when he was brought back into the facility and RN #1 called 911. Resident #1 was shaking vehemently and RN #1 was unable to get a temperature or pulse oximeter (to read the oxygen levels in the body) for the resident. The resident's feet and hands had deep erythema (reddening of the skin) to his fingers and toes with a "waxy" appearance. A hospital progress note, dated 12/24/23 revealed the diagnoses of hypothermia and an altered mental status. On 12/25/23 the hospital documented Resident #1 complained of pain to his toes as they rewarmed. Emergency medical services (EMS) noted the resident was cold with a temperature of 88 degrees Fahrenheit. A nursing progress note dated 12/27/23 revealed a nurse from the facility called the hospital where Resident #1 was staying. The hospital told the facility's nurse Resident #1 was in stable condition and had right lower extremity frostbite. C. Review of the 12/24/23 incidentOn 4/25/24 at 2:00 p.m. the NHA provided the investigation of Resident #1's elopement on 12/24/23. The investigation revealed the following:Resident #1 was seen on the facility's video recording on 12/24/23 at 10:04 p.m. walking around the dining room. At 10:11 p.m. Resident #1 was observed on camera standing in front of the dining room door that led to the outside. The video camera did not record for approximately 1-2 minutes due to connection issues. When the camera turned back on the view was of a closed door, however, Resident #1 was no longer observed on the video. The facility documented Resident #1 went out the dining room door during the video outage and then out the unsecured gate where there was no video coverage. At 10:44 p.m. the camera revealed RN #1 at the front door of the facility talking to a staff member. The agency certified nurse aide (ACNA) #1 said he drove his car to a convenience store nearby and returned from his lunch break around 10:44 p.m. ACNA #1 said he saw a person seated on the ground in the snow who was stuck in an orange construction site fence, a barrier, safety, lightweight fence that separated the facility property from nearby construction. ACNA #1 walked up to the person who was seated on the ground but was unsure if it was one of the residents or a homeless person. ACNA #1 said the area had frequently spotted homeless individuals in the area. ACNA #1 went in the facility to get RN #1 and ACNA #2. RN #1 verified it was one of the facility residents and the two ACNA's used a wheelchair to bring the resident back into the facility. RN #1 documented difficulty obtaining vitals on Resident #1 and RN #1 called for an ambulance to take Resident #1 to the hospital. Resident #1 went to the hospital and did not return to the facility per the family's request. On 12/27/24 (three days after the incident) the facility began investigating the incident. The facility was unable to determine whether the outside gate, which had a code, was left open by the facility staff or was damaged by the homeless individuals who were often seen in the nearby field. The facility investigation determined the agency staff in the building did not recognize the chirping sounds from the alarm to be a warning sound of a door opening. The alarm sound was determined to stop sounding after 90 seconds. Following the 90 seconds, the door did not reset the alarm unless a key was manually used to reset it. On 12/27/24 education was provided to the facility staff and the facility made a binder for all agency staff to read before their shifts to learn what to do in the event a door alarm went off. The facility began monitoring the occurrence in the QAPI meetings on 1/11/24 and planned to monitor for three months or longer as needed. D. Staff interviewsThe NHA was interviewed on 4/25/24 at 2:15 p.m. The NHA said, on 12/27/23, she began training all facility staff on alarming the doors and locking the gate. She said on 12/27/23 she began an elopement book of procedures that she required all agency staff to read before they began a shift in the facility. She said she began monitoring the situation through the QAPI meeting process. The NHA said RN #1 no longer worked at the facility. ACNA #1 was interviewed on 4/29/24 at 4:35 p.m. ACNA #1 said, on 12/24/23, he was the one who found Resident #1 in the field. ACNA #1 said he drove his car to get something to eat around 10:10 p.m. and when he returned around 10:40 p.m. he saw someone in the field next to the facility. He said he approached the man to check if it was a resident or one of the homeless people in the area. He said the man was seated in the snow on his posterior and his legs and hands were stuck in the construction fence. He said he thought it was a resident so he went inside and got the nurse to come outside with him to evaluate the situation. ACNA #1 said RN #1 and ACNA #2 came outside with a wheelchair. He said he and ACNA #2 put Resident #1 in a wheelchair and brought the resident back inside the facility. He said Resident #1 was too cold to get vital signs so RN #1 called 911. He said EMS came shortly after the call and took Resident #1 to the hospital. ACNA #1 said after Resident #1 was safely back inside, he and ACNA #2 checked the alarms on the doors. ACNA #1 said the alarm on the door the resident seemed to have gone out did not sound and the gate outside was opened. He said he reset the alarm when it was discovered it was not on. He said he did not know how long the alarm had been off. ACNA #2 was interviewed on 4/29/24 at 4:56 p.m. ACNA #2 said, on 12/24/23 around 10:40 p.m., he received a text from ACNA #1 to come outside and give him help. He said he brought a wheelchair outside and he and ACNA #1 put Resident #1 in the wheelchair and brought him back into the facility. He said he did not hear an alarm go off that night. He said he and ACNA #1 tried to figure out how Resident #1 got outside of the building. He said ACNA #1 reset the alarms on the door after Resident #1 went to the hospital.-RN #1 was contacted for an interview on 4/29/24 at 5:14 p.m, however, an interview was unable to be conducted. V. Resident #2A. Resident statusResident #2, age under 75, was admitted on 11/15/22. According to the April 2024 CPO, diagnoses included paranoid schizophrenia, unsteadiness on his feet, hypertension (high blood pressure), dementia with behavioral disturbances, history of falls and shortness of breath. The 11/16/23 MDS assessment revealed the resident had short and long term memory problems, continued inattention and disorganized thinking. He had behavioral symptoms occasionally directed at others, kicking, biting, hitting, pushing, scratching or grabbing. He had impaired vision. B. Record reviewThe comprehensive care plan, initiated on 11/21/22 and revised on 12/1/23, revealed Resident #2 was an elopement risk/wanderer with a history of attempts to leave a previous facility he lived in. Due to the resident's progressing dementia, Resident #2 had been determined to be in need of a secured unit facility. Resident #2 had aggressive behaviors related to exit seeking and was not redirectable. Pertinent interventions included identifying the resident's patterns of wandering, nursing to conduct frequent checks for the resident's whereabouts and de-escalating the resident's behaviors through redirection. The comprehensive care plan further revealed the resident had a history of pressing on doors to set off the alarm on them. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. The elopement evaluation, dated 6/20/23, revealed the resident was able to ambulate without the use of assistive devices or a wheelchair. He had a history of elopement. He had a history of trying to leave the facility without informing the staff. He verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door. The resident wandered and it was likely to affect his safety or the safety of others. A hospital progress note, dated after the elopement on 2/2/24, revealed the resident was found wandering in the middle of an intersection by the police and brought to the emergency room. The hospital found the resident to be safe and able to return to the nursing home. A nursing progress note related to the 2/2/24 elopement, documented on 2/3/24, revealed the police called the facility at 10:20 p.m. on 2/2/24 and said Resident #2 was found wandering alone on the street. At 10:30 p.m. the nurse called the police back and answered their questions. On 2/3/24 at 1:25 a.m. Resident #2 returned to the facility on a stretcher from the hospital. C. Review of the 2/2/24 incidentOn 4/25/24 at 2:00 p.m. the NHA provided the investigation of Resident #2's elopement on 2/2/24. The investigation revealed the following:On 2/2/24 at 9:48 p.m. Resident #2 was seen leaving out the same dining room door that Resident #1 went out at 9:48 p.m. on 12/24/23. At 10:20 p.m. the local police department called the facility to ask if the facility was missing a resident. Facility staff were not sure if any residents were missing and said they would look and call the police back. Facility staff did a search of all residents and discovered Resident #2 was missing from the facility. At 10:30 p.m. the facility nurse called the police back and informed them Resident #2 was missing. The police informed the facility Resident #2 was found at a busy intersection approximately one tenth of a mile from the facility and had been taken to a local hospital for an evaluation. Resident #2 returned to the facility from the hospital on 2/3/24 at 1:25 a.m. with no noted injuries. Resident #2 was unable to be interviewed due to cognitive impairment. Resident #2 had a legal representative who was notified of the incident. On 2/3/24 the NHA's investigation revealed the dining room door to the outside had an alarm that did not go off and sound. Staff said they were not in the area of the dining room and did not hear the alarm sound. Again the outside gate was unlocked and it was not determined if a staff person did not lock the gate or a homeless person from the nearby areas opened the gate. D. Staff interviewsThe NHA was interviewed on 4/25/24 at 2:15 p.m. The NHA said after Resident #2 was the second resident to elope from the facility, she determined the alarm system needed to be replaced and more education needed to be provided to the facility staff as well as any agency staff that worked in the building. She said the building had ongoing agency staff working in the building. She said she called the agency where the staff came from and informed them that all agency staff who came to work at the facility had to read the policy of elopement and what the process was to keep the door alarms on. The regional director of plant operations (RDPO) was interviewed on 4/25/24 at 2:53 p.m. over the phone. The RDPO said he came in a day or two after the 12/25/23 elopement incident to evaluate what had happened with the alarm system and the outside gate lock. The RDPO said after the first elopement investigation, it seemed possible that a staff person did not reset the alarm prior to Resident #1 leaving the facility. He said the alarm shut off in 90 seconds and needed a key to turn the alarm back on. He said it seemed, through education of the staff, the situation would be fixed. The RDPO said the second time there was an elopement, on 2/2/24, he came in the next day. He said he determined, along with the NHA, that a new alarm system needed to be installed. He said the outside gate also needed to have something new installed. He said new alarms were installed on the dining room door where the residents eloped from. The RDPO said it was determined that a security camera needed to be installed in the back gate area. He said he contacted (name of approving agency) to get approval to redesign and install a new egress area between the dining room door and the gate. He said the parts for the door alarm were ordered and put up around 2/7/24. The RDPO said as soon as he had approval, the egress area parts were ordered, and the installation took a few days. He said the egress was completed sometime at the end of February 2024. The RDPO said he and the NHA looked at everything after the first elopement and they thought education to the staff was the solution but it was not good enough. He said after the second elopement, he designed an entirely new solution. The RDPO said the second solution worked because no residents had eloped since the new system was put in place. CNA #3 was interviewed on 4/30/24 at 10:01 a.m. CNA #3 said she was working in the front part of the facility on the night Resident #2 eloped. She said the nurse on duty told her the police called to ask if the facility was missing a resident. CNA #3 said the staff began a head count of the residents and discovered Resident #2 was not in the facility. CNA #3 said staff checked the dining room door and the alarm was disarmed and the gate door was opened in the egress section. CNA #3 said she did not know who disarmed the alarm or when it happened. She said the staff did not know Resident #2 was gone out of the facility until the police called to tell them. Agency registered nurse (ARN) #1 was interviewed on 4/30/24 at 10:45 a.m. ARN #1 said he was told by his staffing agency to read the binder in the facility before he worked and then sign that he acknowledged what he read. He said the binder contained instructions on how to respond when the alarms sounded. He said he could hear the alarms clearly in the halls and resident rooms. He said the alarms took a key to shut off the alarm and reset the alarm. CNA #2 and CNA #3 were interviewed on 4/30/24 at 11:20 a.m. Both CNAs said they never entered for work through the gate where the residents eloped. Both CNAs said when a resident pushed on a door, an alarm sounded that was loud enough for them to hear wherever they were working in the building. Both CNAs said the alarm continued to sound until someone came with the key to turn the alarm off and reset the alarm. The NHA was interviewed again on 5/1/24 at 10:00 a.m. The NHA provided documentation of the QAPI process. She said all facility management, the pharmacist, and the medical director attended the QAPI meeting. The NHA said after the incident on 12/24/23 a review at QAPI began immediately in January 2024. She said the QAPI committee met one time per month. The NHA said she had hoped the review would be completed within three months after the 12/24/23 incident but it was not done in three months because of the 2/2/24 elopement. The NHA said the elopement situation would be reviewed in QAPI for at least three months, through May 2024 or longer if the situation needed more review. The NHA said the alarms and gates would be monitored weekly indefinitely.