CENTER AT LOWRY, LLC

Initial comments, identified under ID Prefix Tag K0000, are informational in nature and are intended to reflect the general characteristics of the facility. This Life Safety Code survey was conducted in accordance with the Federal Register, 42 CFR §483.90(a). The facility is a 76,649 square foot, three-story structure of Type II (111) construction divided into six smoke compartments, two per floor. The facility is licensed for 96 beds, with a resident census of 66 at the time of the survey. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry fire sprinkler system. The facility is classified as fully sprinklered. The survey was conducted on May 01, 2026, to determine compliance with the following applicable codes and standards: NFPA 101 (2012 Edition), Life Safety Code, Chapter 19 — Existing Health Care OccupanciesNFPA 99 (2012 Edition), Health Care Facilities CodeAll other applicable referenced codes and standards Deficiency findings identified during the survey were reviewed on-site and were subsequently discussed during the exit conference with the executive director (ED), and maintenance director (MD).

Based on observations and staff interviews during the survey the facility failed to maintain the kitchen equipment as required by NFPA 101 (2012), Life Safety Code, NFPA 96 (2011), Ventilation Control and Fire Protection of Commercial Cooking Operations, and all applicable referenced codes and standards. Specifically, commercial cooking appliances requiring protection were not provided with a method to ensure that the appliance could be returned to an approved design location if moved. This deficient practice had the potential to affect one of six smoke compartments and could impact all occupants within the affected area, including staff, visitors, and 96 of 96 residents. The executive director (ED) and maintenance director (MD) were present during the survey. Findings Include:Commercial cooking appliances requiring protection were not provided with a method to ensure that appliances could be returned to an approved design location if moved for maintenance or cleaning. Regulatory ReferencesNFPA 101 (2012), § 4.6.12.1 – Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 96 (2011), Chapter 12 – Minimum Safety Requirements for Cooking EquipmentNFPA 96 (2011), § 12.1.2.2 – Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior re-evaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by design of the fire extinguishing system. NFPA 96 (2011), § 12.1.2.3 – The fire-extinguishing system shall not require re-evaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to the approved design location prior to cooking operations, and any disconnected fire-extinguishing system nozzles attached to the appliances are reconnected in accordance with the manufacturer’s listed design manual. NFPA 96 (2011), § 12.1.2.3.1 – An approved method shall be provided that will ensure that the appliance is returned to an approved design location. Deficiency findings were discussed during the survey and again at the exit conference with the ED and MD.

Based on record review, and staff interviews, the facility failed to maintain fire alarm components and devices in accordance with NFPA 101 (2012), Life Safety Code, and NFPA 72, National Fire Alarm and Signaling Code. Specifically, no ITM records were provided at time of survey to verify that the sensitivity of smoke detectors had been tested within 2 years. This deficient practice had the potential to affect six of six smoke compartments, and to impact visitors, staff, and 96 of 96 residents. The executive director (ED) and maintenance director (MD) were present during the survey. Findings Include:No ITM records were provided at time of survey to verify that the sensitivity of smoke detectors/alarms had been tested within 2 years. Regulatory References:NFPA 101 (2012)§ 19.3.4 Detection, Alarm, and Communications Systems.§ 19.3.4.1 Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. § 9.6 Fire Detection, Alarm, and Communications Systems.§ 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 72 (2010)Chapter 14 Inspection, Testing and Maintenance§ 14.4 Testing§ 14.4.5.3 … sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7.§ 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.§ 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.§ 14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed an marked sensitivity range, it shall be tested using any of the following methods:Calibrated test methodManufacturer’s calibrated sensitivity test instrumentListed control equipment arranged for the purposeSmoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity rangeOther calibrated sensitivity test methods approved by the authority having jurisdiction Deficiency findings were discussed during the survey and again at the exit conference with the ED and MD.

Based on record review, and staff interviews, the facility failed to ensure that the automatic sprinkler system was inspected, tested and maintained in accordance with NFPA 101 (2012), Life Safety Code, and NFPA 25, Standard for the Inspection, testing, and Maintenance of Water-Based Fire Protection Systems. Specifically, multiple ITM records included a deficiency note that the Control Valve in room 331 was not tested due to a sleeping resident in the room. This deficient practice had the potential to affect two of six smoke compartments, and to impact visitors, staff, and 48 of 96 residents. The executive director (ED) and maintenance director (MD) were present during the survey. Findings Include:Upon review of the inspection, testing, and maintenance records that were provided for the facility’s automatic sprinkler system it was found that the required inspections and tests for the Control Valve on the 3rd floor above room 331 was not completed. Multiple records stated that the vendor could not access the control valve because there was a resident sleeping in the room. Staff were unable to provide records demonstrating compliance with required testing and maintenance. Regulatory ReferencesNFPA 101 (2012), § 4.6.12.1 – Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design or as directed by the authority having jurisdiction. NFPA 101 (2012), § 9.7.5 – All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25 (2011), § 13.1.1.1 – This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of valves, valve components, and trim. NFPA 25 (2011), § 13.1.1.2 – Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. Control Valves (item / frequency / reference)Sealed / weekly / § 13.3.2.1 Locked / monthly / § 13.3.2.1.1 Tamper switches / monthly / § 13.3.2.1.1 Alarm valvesExterior / monthly / § 13.4.1.1 Interior / 5 years / § 13.4.1.2Strainer, filters, orifices / 5 years / § 13.4.1.2Check ValvesInterior / 5 years / § 13.4.2.1 Deficiency findings were discussed during the survey and again at the exit conference with the ED and MD.

Based on observations and staff interviews during the survey the facility failed to maintain the integrity of the smoke barrier doors and means of egress as required by NFPA 101 (2012), Life Safety Code, and applicable referenced codes and standards. Specifically, the smoke barrier doors between the kitchen/serving area (154) and the dining area (169) had additional hasp locks installed on the kitchen side of the smoke barrier doors. Through staff interviews I was informed that the kitchen added the locks to keep residents out of the area. This deficient practice had the potential to affect two of six smoke compartments and could impact all occupants within the affected area, including staff, visitors, and 96 of 96 residents. The executive director (ED) and maintenance director (MD) were present during the survey. Findings Include:The smoke barrier doors between the kitchen/serving area (154) and the dining area (169) had additional hasp locks installed on the kitchen side of the smoke barrier doors. Regulatory ReferencesNFPA 101 (2012), § 4.6.12.1 – Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 101 (2012), § 7.2.1.1.3.2 – Where means of egress doors are locked in a building that is not considered occupied, occupants shall not be locked beyond their control in buildings or building spaces, except for lockups in accordance with 22.4.5 and 23.4.5, detention and correctional occupancies, and health care occupancies. NFPA 101 (2012), § 7.2.1.5.3 – Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. NFPA 101 (2012), § 7.2.1.5.12* – Devices shall not be installed in connection with any door assembly on which panic hardware or fire exit hardware is required where such devices prevent or are intended to prevent the free use of the leaf for purposes of egress, unless otherwise provided in 7.2.1.6. NFPA 101 (2012), A.?7.2.1.5.12 – Examples of devices prohibited by this requirement include locks, padlocks, hasps, bars, chains, or combinations thereof. NFPA 101 (2012), 7.2.1.15.2 – Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. NFPA 101 (2012), § 19.2.2.2.4 – Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following:Locks complying with 19.2.2.2.5 shall be permitted. Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted. Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted. Approved existing door-locking installations shall be permitted. Deficiency findings were discussed during the survey and again at the exit conference with the ED and MD.

Based on record review and staff interviews, the facility failed to maintain the HVAC system in accordance with the requirements of NFPA 101 (2012), Life Safety Code, and NFPA 105 (2010), Standard for Smoke Door Assemblies and Other Opening Protectives. Specifically, the facility failed to provide current and accurate ITM reports verifying the repair or replacement of two fire/smoke dampers that were identified as failed and in need of replacement. This deficient practice had the potential to affect four of six smoke compartments, and to impact visitors, staff, and 96 of 96 residents. The executive director (ED) and maintenance director (MD) were present during the survey. Findings Include:Review of the ITM report dated 04/10/2024 revealed that two fire/smoke dampers failed and are in need of replacement. Specifically, dampers FSD-8, and FSD-078. During interviews at that time, facility staff could not provide current documentation verifying that the deficient practice had been corrected. Regulatory References:NFPA 101 (2012), § 4.6.12.1 – Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design or as directed by the authority having jurisdiction. NFPA 101 (2012), § 8.5.5.4.2 – Smoke dampers and combination fire and smoke dampers required by this Code shall be inspected, tested, and maintained in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. NFPA 105 (2010), Chapter 6 – Installation, Testing, and Maintenance of Smoke DampersNFPA 105 (2010), § 6.5 – Periodic Inspection and Testing. NFPA 105 (2010), § 6.5.2 – Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. NFPA 105 (2010), § 6.5.11 – All inspections and testing shall be documented indicating the location of the damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. NFPA 105 (2010), § 6.6 – Maintenance. NFPA 105 (2010), § 6.6.3 – If the damper is not operable, repairs shall begin as soon as possible. NFPA 105 (2010), § 6.6.4 – Following any repairs, the damper shall be tested for proper operation in accordance with Section 6.5. NFPA 105 (2010), § 6.6.6 – All maintenance shall be documented and records shall be retained in accordance with 6.5.11 and 6.5.12. Deficiency findings were discussed during the survey and again at the exit conference with the ED and MD.

Based on record review, and staff interviews, the facility failed to maintain the emergency electrical system, components, and devices in accordance with NFPA 101 (2012), Life Safety Code, and NFPA 110, Standard for Emergency and Standby Power Systems. Specifically, no annual ITM records were provided at time of survey to verify that the annual fuel quality test had been performed. This deficient practice had the potential to affect six of six smoke compartments, and to impact visitors, staff, and 96 of 96 residents. The executive director (ED) and maintenance director (MD) were present during the survey. Findings Include:No ITM records were provided at time of survey to verify that the annual fuel quality test had been performed. Regulatory References:NFPA 101 (2012), § 4.6.12.1 – Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design or as directed by the authority having jurisdiction. NFPA 101 (2012), § 9.1.3.1 – Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 (2010), § 8.1.1 – The routine maintenance and operational testing program shall be based on all of the following:Manufacturer’s recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdictionNFPA 110 (2010), § 8.3.3 – A written schedule for routine maintenance and operational testing of the EPSS shall be established. NFPA 110 (2010), § 8.3.4 – A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available. NFPA 110 (2010), § 8.3.4.1 – The permanent record shall include the following:The date of the maintenance reportIdentification of the servicing personnelNotation of any unsatisfactory condition and the corrective action taken, including parts replacedTesting of any repair for the time as recommended by the manufacturerNFPA 110 (2010), § 8.3.8 – A fuel quality test shall be performed at least annually using tests approved by ASTM standards. NFPA 110 (2010), § 8.4.2 – Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturerUnder operating temperature conditions and at not less than 30 percent of the EPS nameplate kW ratingNFPA 110 (2010), § 8.4.2.3 – Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. Deficiency findings were discussed during the survey and again at the exit conference with the ED and MD.

A recertification survey with complaint #CO2637344, #CO2671944, #CO2960871, #CO2962718 and Incident #2962831 was conducted on 3/30/26 to 4/2/26. Three deficiencies were cited.

An Emergency Preparedness survey was conducted from 3/30/26 to 4/2/26. No deficiencies were cited.

Based on observations, record review, and interviews, the facility failed to ensure one (#8) of nine residents out of 30 sample residents was provided services that met professional standards of quality. Specifically, the facility failed to ensure Resident #8’s medications were administered in a timely manner and not left at the resident’s bedside. Findings include: I. Professional referenceAccording to the National Institutes of Health (NIH), National Library of Medicine, Nursing Rights of Medication Administration (September 2023), retrieved on 4/6/26 from https://www.ncbi.nlm.nih.gov/books/NBK560654, "It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. Incorrect time is a prevalent modality of medication administration error. This error type stems from nurses giving a patient medication at an incorrect time, even if it is the correct medication and the patient’s identity is verified, without first checking to ensure it is the correct time for the medication to be administered to the patient.”II. Facility policy and procedure The Medication Administration policy and procedure, revised 4/2/24, was provided by the director of nursing (DON) on 4/2/26 at 3:15 p.m. It read in pertinent part, “It is the policy of this facility that medications are to be administered as prescribed by the attending physician. Medications must be administered in accordance with the attending physician's written orders. Medications may not be set up in advance and must be administered one hour before or one hour after their prescribed time.” III. Resident #8A. Resident statusResident #8, age 65, was admitted on 3/20/26. According to the April 2026 computerized physician orders (CPO), diagnoses included surgical after care following surgery to the nervous system (lumbar surgery), radiculopathy to the lumbar region (pinched nerve resulting in sciatica), multiple sclerosis, difficulty walking, pulmonary embolism (sudden blockage in a lung artery), hypertension, long-term use of anticoagulant medications and major depressive disorder. The 3/30/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required partial assistance with activities of daily living (ADL) and moderate assistance for ambulation. He used a walker and a wheelchair. B. ObservationsOn 3/30/26 at 2:15 p.m. a medication cup with two tablets in it was sitting on the cover of Resident #8’s lunch tray. On 3/30/26 at 2:43 p.m. the same medication cup with two tablets in it was still sitting on Resident #8’s lunch tray. On 3/30/26 at 2:45 p.m., upon prompting, LPN #3 entered Resident #8’s room and administered the two tablets in the medication cup on the resident’s lunch tray cover to Resident #8.-However, the medications were administered over an hour after the allowed medication administration time (see record review below). C. Resident interviewResident #8 was interviewed on 4/1/26 at 11:12 a.m. Resident #8 said that he did not know if the medication cup with the two tablets in it that was left on his bedside table the day prior (3/31/26) was his medication. D. Record reviewReview of Resident #8's March 2026 medication administration records (MAR) revealed the following medications were to be administered to Resident #8 at 12:00 p.m.: Gabapentin (anticonvulsant medication primarily used to treat neuropathic pain and partial seizures). Give one 600 milligram (mg) tablet by mouth three times a day, ordered 3/30/26. Cyclobenzaprine HCl (muscle relaxant used for muscle spasms). Give one 10 mg tablet by mouth three times a day, ordered 3/24/26. -However, the medications were observed sitting in a medication cup over one hour after the allowed medication administration time (see observations above). IV. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 3/30/26 at 2:45 p.m. LPN #3 entered Resident #8’s room and said the resident had been in the bathroom when he (LPN #3) came to administer the resident’s medications. LPN #3 said he left the resident's medications on the bedside table and exited the room. LPN #3 said it was inappropriate to leave medication on the resident's bedside table and not observe the resident taking the medication. LPN #3 said one tablet in the medication cup was Neurontin (gabapentin) and the other was cyclobenzaprine. The director of nursing (DON) was interviewed on 4/1/26 at 10:50 a.m. The DON said that LPN #3 had told her that Resident #8 was on the phone when he went to administer the medications to the resident. The DON said LPN #3 said he left the resident's medication on the bedside table and exited the resident's room. The DON said it was not appropriate to leave medications with a resident and not observe the resident taking the medication.

Based on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for two of five medication carts. Specifically, the facility failed to:-Ensure medications, such as inhalers, eye drops and tuberculin purified protein derivative (PPD - a skin test antigen used to detect infection with tuberculosis) were dated when opened;-Ensure medications were not stored in a medication cup instead of a labeled medication bottle in the medication cart; and,-Ensure loose pills were not in the bottom of the medication cart drawers. Findings include:I. Professional referenceAccording to Drugs.com (1/23/25) Can You Use An Expired Albuterol Inhaler?, retrieved on 4/6/26 from https://www.drugs.com/medical-answers/you-expired-albuterol-inhaler-3556003/,“An albuterol inhaler should be discarded after it passes its expiration date. It should be thrown out even sooner if it has been 13 months since it was removed from its foil packaging.”According to the Spiriva Respimat (tiotropium bromide) inhaler package insert, retrieved on 4/6/26 from https://pro.boehringer-ingelheim.com/us/products/spiriva/copd/, “After assembly, the Spiriva Respimat inhaler should be discarded, at the latest, three months after first use or when the locking mechanism is engaged, whichever comes first.”According to Drugs.com (10/27/25), Arnuity Ellipta: Package Insert/Prescribing Info, retrieved on 4/9/26 from https://www.drugs.com/pro/arnuity-ellipta.html.“Discard Arnuity Ellipta six weeks after opening the foil tray or when the counter reads “0” (after all blisters have been used), whichever comes first.”According to Drugs.com (12/29/25) Xalatan Package Insert/Prescribing Information, retrieved on 4/9/26 from https://www.drugs.com/pro/xalatan.html“Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees celsius (C) (77 degrees Fahrenheit (F) for six weeks.”According to Drugs.com (10/10/24), Tuberculin Purified Protein Derivative (Interdermal) (monograph), retrieved on 4/8/26https://www.drugs.com/monograph/tuberculin-purified-protein-derivative-interdermal.html#:~:text=for%20intradermal%20injection.-,Administration,Mantoux%20Test“Tuberculin PPD, diluted (Aplisol), is supplied as multi-dose vials containing 5 Tuberculin Units (TU) per 0.1 milliliters (ml) for intradermal injection. Store vials at 2 to 8 degrees C (36-46 degrees F); do not freeze; protect from light. Vials in use for more than 30 days should be discarded due to possible oxidation and degradation, which may affect potency.”II. Facility policy and procedureThe Storage of Medications policy, revised 2/9/26, was provided by the director of nursing (DON) on 4/1/26 at 3:34 p.m. It read in pertinent part,“Medications are stored properly, following pharmacy or provider instructions to maintain their integrity and support safe, effective medication administration. The pharmacy dispenses the medication in containers with labels. Medications are to remain in the containers until dispensing. Medications requiring refrigeration are kept refrigerated. Outdated, discontinued, and expired medications should be removed from stock. Medication storage should be kept clean, organized, and free of clutter. Medication storage conditions are monitored randomly as a quality assurance program.”III. ObservationsOn 3/30/26 at 8:20 a.m. the second floor medication cart A was observed with registered nurse (RN) #3. The following items were found: One bottle of Xalatan (latanaprost 0.005%) eye drops (used to reduce high eye pressure) was not dated when opened. One vial of tuberculin (PPD) was not dated when opened and was being stored in the medication cart and not the refrigerator. One Spiriva inhaler (medication used to help open airways to improve breathing) was not dated when opened. One loose pill was in the bottom of the second drawer of the medication cart. There was a medication cup sitting in the top drawer of the medication cart. The medication cup contained seven burgundy colored softgel tablets. The medication cup was not labeled with a resident’s name or the medication name of the softgel tablets. On 3/30/26 at 8:40 a.m. the third floor medication cart C was observed with RN #4. The following items were found:Two Albuterol inhalers were not dated when opened. One Spiriva inhaler was not dated when opened. One Arnuity Ellipta inhaler (inhaled medication used to treat asthma) was not dated when opened. Seven loose pills were in the bottom of the second drawer of the medication cart. IV. Staff interviewsRN #3 was interviewed on 3/30/26 at 8:20 a.m. RN #3 said the nurses cleaned the medication carts on each shift. RN #3 said the one loose medication at the bottom of the second drawer of the second floor medication cart A was a Senna Plus (medication used to treat constipation). RN #3 said the risk of not putting an open date on the medication was giving an expired medication. RN #3 said expired medications may not be effective. She said the burgundy colored softgel tablets sitting in the medication cup in the top drawer of the medication cart were Preservision Eye Supplement tablets. She said she ran out of the medication in her cart and went to another medication cart to get some. She said she poured seven softgel tablets from the over the counter medication bottle in the other cart into a medication cup and brought them back to her medication cart. RN #4 was interviewed on 3/30/26 at 8:40 a.m. RN #4 said every nurse was responsible for cleaning the medication carts on each shift that they worked. RN #4 said she knew that two of the loose medications in the bottom of the second drawer of the third floor medication cart C were acetaminophen (medication used to treat pain and fever) and one loose medication was omeprazole (medication that reduces stomach acid). She said she was not sure what the other four loose medications were. RN #4 said the risk of loose medications was that a medication could drop to the floor and be taken by a resident. RN #4 said nurses should always put an open date label on medications so they knew when the medication expired. She said expired medications might no longer be potent. The DON was interviewed on 4/1/26 at 10:50 a.m. The DON said it was the nurses’ responsibility to clean the medication carts on their shifts. The DON said there should not be any medications in a medicine cup without a label in the medication cart. The DON said it was important for the nurses to mark medications with an open date to prevent giving an expired medication because the medication might then be ineffective.

Based on observations and interviews the facility failed to distribute food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure employees performed hand hygiene appropriately during meal service. Findings include:I. Professional referenceThe Colorado Retail Food Regulations, (3/16/24), retrieved on 4/6/26, read in pertinent part, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands." (2-301.15)II. ObservationsDuring a continuous observation on 3/31/26, beginning at 5:08 p.m. and ending at 5:30 p.m., the following was observed during meal service in the main kitchen:At 5:10 p.m. cook (CK) #1 had gloves on and was touching several high traffic surface areas (counter tops, the refrigerator handle and using utensils to plate the meal). Without changing gloves, CK #1 used the same gloved hands to retrieve clean plates and clean bowls for service. He placed gloved hands on the eating surfaces of the clean dishware. Without performing hand hygiene, CK #1 used the same gloved hands to place bread on the plates. At 5:20 p.m. CK #1 had not changed his gloves and touched the counter top of the serving table, wiped the sneeze guard top with his gloved hand and used utensils for plating food. CK #1 took carrots to a cutting station with the same gloved hands. He used a knife and scooped up carrots to plate the carrots with the same gloved hands. CK #1 continued to plate bread without utensils wearing the same gloves. -During the observation time, CK #1 had not changed his gloves during service, although he had left the service area, touched the refrigerator handle, picked up utensils and touched counter tops prior to handling plates and food. During a continuous observation on 4/1/26, beginning at 11:27 a.m. and ending at 12:17 p.m. the following was observed during meal service in the main kitchen:At 11:31 a.m. the dietary manager (DM) put on gloves and took plates from the clean dish rack for service. With the same gloved hands, he scooped up lettuce and plated the lettuce for a salad. He then used utensils to put the toppings on the salad. He continued to use the same gloved hands for scooping the lettuce. Without changing gloves, the DM placed rolls on the plates with his gloved hands. He left the service area to retrieve more plates, touching the eating surface of the plates, and scooped the lettuce without changing his gloves. At 11:36 a.m. CK #2 washed his hands and put on gloves. He then left the service area to retrieve wrapped sandwiches from the reach-in refrigerator with the same gloves. With the same gloved hands, he unwrapped the sandwiches and used his gloved hands to steady the sandwiches while he cut them in half. He then plated the sandwiches with the same gloved hands. At 11:41 a.m., with the same gloved hands, CK #2 went to the grill and removed cooked chicken with a utensil, cut the chicken on the cutting board and then scooped up the chicken with his gloved hands and plated the chicken for a resident. At 11:45 CK #2 removed his gloves, washed his hands and donned (put on) another pair of gloves. He then returned to the refrigerator with the gloves on, removed more sandwiches, unwrapped the sandwiches, placed them on the cutting board and placed his hands on the sandwiches to stabilize them while he cut them in half, then plated each sandwich. -During the continuous observation, CK #2 had not removed his gloves after touching high surface areas, such as the refrigerator handle, counter tops, the top of the sneeze guard and leaving the service area before handling food. With gloved hands he touched his personal clothing and went back to touching food without changing gloves. At 11:50 a.m. the DM put on gloves, touched several surfaces and scooped the lettuce with his gloved hands. He used utensils for salad toppings and without changing gloves placed bread on each plate. -During this time, without changing gloves, the DM retrieved a bag of sliced bread, removed the bread from the bag and made sandwiches after touching several surfaces. III. Staff interviewsCK #2 was interviewed on 4/1/26 at 12:18 a.m. CK #2 said hands should be washed before handling food. He said gloves should be changed when they were dirty or greasy. CK #2 said hands should be washed in between changing gloves. He said he changed gloves often, especially when moving to spots such as the serving line to the grill. The DM was interviewed on 4/2/26 at approximately 10:00 a.m. The DM said gloves should be changed when surfaces were touched and before handling food. He said if a staff member stepped away from the service area, they should remove gloves, wash hands and put on new gloves before starting food service. The DM said the staff should use utensils when plating food and not their hands. The DM said he was in the process of starting to have his staff go through an online food safety course.

A survey with #CO2960872 was completed on 3/30/26 to 4/2/26. No deficiencies were cited.

A complaint survey prompted by #CO2655268 and Incident #2659998 was conducted 11/3/25 to 12/10/25. Two deficiencies were cited. The actual survey exit date was 11/5/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider on 12/10/25.

Based on record review and interviews, the facility failed to notify the resident’s physician when there was a significant change in the resident’s condition for one (#1) of two residents out of 12 sample residents. Specifically, the facility failed to notify the physician for Resident #1 when she had slurred speech. Findings include: I. Professional referenceAccording to Nursing Skills (2023), retrieved on 11/17/25 from https://www.ncbi.nlm.nih.gov/books/NBK596735/, “Document and notify physician if new unexpected findings including slurred words or inability to speak. Critical findings to report immediately and or obtain emergency assistance include slurred speech or inability to speak.”II. Facility policy and procedureThe Change in Condition policy, revised 4/2/24, was provided by the director of operations on 11/5/25 at 1:55 p.m. It read in pertinent part, “As part of the evaluation, the nurse will help identify individuals for having any changes of condition during their stay. In addition, the nurse shall evaluate and document/report difficulty speaking. The nursing staff will notify the physician if any of the above signs and symptoms are identified. The physician will indicate if the patient requires additional evaluation/ treatment at the facility or if the resident needs to be sent out to the hospital.”III. Resident #1A. Resident status Resident #1, age 87, was admitted on 10/12/25 and discharged to the hospital on 10/21/25. According to the October 2025 computerized physician orders (CPO), diagnoses included cerebral infarction (an artery is blocked by a clot leading to brain tissue death from a lack of oxygen) due to unspecified occlusion or stenosis of right carotid arteries, type 2 diabetes mellitus and essential hypertension (high blood pressure). According to the 10/18/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She used a walker and a wheelchair. She required set up assistance with eating and supervision with oral and personal hygiene. She required moderate assistance with toileting. B. Record reviewThe 10/18/25 nurse progress note revealed the resident experienced a brief episode of slurred speech during assessment in the morning. The slurred speech resolved and the resident appeared back to baseline. Her vital signs were within normal limits. There was no facial droop observed. Her extremities were equal and strong. The resident was alert and responsive. The facility would continue to monitor for any recurrence. -However, there was no documentation to indicate the resident’s physician was notified of the resident’s episode of slurred speech. The 10/22/25 nurse progress note revealed Resident #1 was again found in her room with slurred speech. At the initial assessment, the resident was alert and at baseline with bilateral upper and lower extremity strength equal. Her vital signs were within normal limits. The physician was notified and assessed the resident at the bedside. The physician ordered a transfer of the resident to the hospital. 911 was called and emergency medical services (EMS) arrived fifteen minutes later. Upon EMS arrival, the resident was noted with mild confusion and generalized weakness. The resident was transferred to the hospital. Resident #1 has a history of a recent stroke and had a remote cardiac monitor attached to her upper chest during the event. The resident’s family was updated. The 10/22/25 hospital history and physical physician note revealed Resident #1 had nonsensical speech upon exam. The nursing facility was called by the hospital and the facility reported the resident was normally sociable with intermittent slurred speech. When the facility noted the resident’s speech was slurred again, a neurological exam was completed that was okay. The nursing facility’s physician was notified and recommended calling 911. The facility reported this happened last Saturday (10/18/25) but wasworse today (10/22/25) with weakness and confusion. The episode on 10/18/25 was brief.-However, the facility’s physician was not notified that the resident was exhibiting slurred speech until the resident’s second episode of slurred speech on 10/22/25, despite the fact that she had initially demonstrated slurred speech on 10/18/25, four days prior to being transferred to the hospital (see progress notes above). IV. Staff interviews Registered nurse (RN) #1 was interviewed on 11/5/25 at 12:07 p.m. RN #1 said he was the nurse who assessed Resident #1 on 10/18/25. RN #1 said Resident #1 had slurred speech so he completed an assessment and notified his assistant director of nursing (ADON) because it was a change in condition for the resident. RN #1 said the ADON completed an assessment. RN #1 was interviewed a second time on 11/5/25 at 12:30 p.m. RN #1 said the ADON did not tell him to notify the physician about Resident #1’s slurred speech on 10/18/25. RN#1 said he notified the ADON because he did not know the resident’s baseline due to the fact that 10/18/25 was the first full shift he had cared for the resident. The ADON was interviewed on 11/5/25 at 12:15 p.m. The ADON said she worked on 10/18/25 and was notified by RN #1 about Resident #1’s slurred speech. The ADON said she completed vital signs and an assessment on the resident together with RN #1 and she told RN #1 to document the findings. The ADON said the physician should have been notified and she said she told RN #1 to notify the physician on 10/18/25. The ADON was interviewed a second time on 11/5/25 at 12:30 p.m. The ADON said if a resident had slurred speech, an assessment should be completed because it could indicate a change in condition. She said she documented the assessment in a progress note. She said the physician, the director of nursing (DON) and the resident’s representative should be notified. The director of nursing (DON) was interviewed on 11/5/25 at 1:10 p.m. The DON said a change of condition included an episode of slurred speech. She said if a nurse observed slurred speech with a resident, the physician should be contacted. The DON said the nurse should also notify the unit manager and the ADON or the DON. The DON said she was familiar with Resident #1. She said if a nurse observed slurred speech with the resident on 10/18/25, she hoped the nurse would have contacted the physician. She said if the nurse had notified the ADON, the nurse should have also notified the physician. She said she thought the facility had discussed Resident #1’s slurred speech in morning rounds, but she was not sure and she would check. She said RN #1 or the ADON may have notified the physician but they did not document that the physician was notified. The DON said based on Resident #1’s insurance, the physician was notified electronically, not by phone, and she would check to see if there was documentation on the back end. V. Facility follow-up The nursing home administrator (NHA) provided the following typed document on 11/6/25 at 2:16 p.m.: “The nurse very appropriately performed a thorough evaluation, documenting his findings and plan moving forward. The nurse was clear, indicating the event was brief and had fully resolved. Resident #1’s vital signs were stable. The resident was back to baseline. The nurse would continue to monitor for any recurrence. The facility believed it was important to note the identification of transient changes in speech had been a common historical finding. Documentation reflects the anomalies tended to come and go and were thought to be the result of past neurological events. The documented treatment plan simply focused on working on compensatory strategies. The 10/11/25 hospital speech language pathology evaluation revealed a recommendation for home speech language pathology due to the resident reporting intermittent word finding difficulties since the previous transient ischemic attack (TIA) which she described as frustrating at times. -However, RN #1, the ADON and the DON said if a resident had slurred speech, the physician should be notified. The facility did not document transient changes during the resident’s stay at the facility to determine slurred speech was the resident’s baseline.

Based on observations, record review and interviews, the facility failed to ensure four (#1, #3, #2 and #4) of five residents out of 12 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to: -Ensure staff followed the physician's orders for Resident #1’s anti-fungal medication;-Ensure staff followed the physician's orders for Resident #3’s skin treatment; and, -Ensure staff obtained a physician’s order before providing skin treatment for Resident #2 and Resident #4. VI. Resident #4A. Resident statusResident #4, age 87, was admitted to the facility on 10/30/25. According to the November 2025 CPO, diagnoses included cellulitis (skin infection caused when germs enter through a crack in the skin) of left lower limb, edema and difficulty in walking. The 11/4/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The functional and mobility assessment had not been completed at the time of the survey. B. Resident interviewResident #4 was interviewed on 11/4/25 at 9:40 a.m. Resident #4 said he was not aware of his wound care treatment schedule. He said WCN #1 provided wound care treatment to both legs on 10/31/25. Resident #4 said licensed practical nurse (LPN) #1 provided wound care to his left leg on 11/3/25 but did not complete the treatment for his right leg. He said he asked LPN #1 about the treatment for the right leg, and LPN #1 told him she could not complete it at that time. Resident #4 said LPN #1 left the room and did not come back. C. Record reviewThe skin care plan, initiated 10/30/25 and revised 11/4/25, documented Resident #4 had a potential for skin breakdown related to impaired mobility secondary to weakness and debility. Interventions included completing dressing changes per physician’s order, notifying the physician of any signs and symptoms of infections and completing skin evaluations as ordered and as needed. The wound care evaluation, dated 10/31/25, documented a vascular wound on the front of Resident #4’s left lower leg. The wound measured 19 cm in length by 15 cm in width with 0.1 cm in depth. The evaluation documented another vascular wound on the rear of Resident #4’s right lower leg. The wound measured 15 cm in length by 15 cm in width with 0.1 cm in depth. The 10/31/25 progress note revealed WCN #1 cleansed, dried, and placed silver antimicrobial gel (wound care treatment) on the wounds. WCN #1 overlaid the wounds with an adaptec dressing, covered with an abdominal (ABD) pad, wrapped with kerlix, and secured with an ace wrap.-However, there was no documentation in the resident’s October 2025 CPO indicating an active physician’s order for the wound treatment provided on 10/31/25. Review of Resident #4’s November 2025 CPO revealed the following physician’s orders: Normal saline with instructions to cleanse and pat dry every other day for the left lower extremity wound, ordered 11/2/25. Silver antimicrobial gel with instructions to apply to open areas every other day for the left lower extremity wound, ordered 11/2/25. Adaptec dressing and abdominal pad with instructions to cover the left lower extremity wound, ordered 11/2/25. Kerlix and Ace wrap with instructions to wrap the lower left lower extremity wound, ordered 11/2/25.-Review of the November 2025 CPO revealed the resident did not have physician’s orders for the right lower extremity wound until 11/4/25, during the survey (see physician’s orders below). The November 2025 CPO revealed the following physician’s orders: Normal saline with instructions to cleanse and pat dry every other day for the right lower extremity wound, ordered 11/4/25. Silver antimicrobial gel with instructions to apply to open areas every other day for the right lower extremity wound, ordered 11/4/25. Adaptec dressing and abdominal pad with instructions to cover the right lower extremity wound, ordered 11/4/25. Kerlix and Ace wrap with instructions to wrap the lower right lower extremity wound, ordered 11/4/25. VII. Staff interviewsWound care nurse (WCN) #1 was interviewed on 11/4/25 at 2:53 p.m. WCN #1 said she had worked at the facility for one month and was the wound care nurse for all residents. WCN #1 said residents’ skin was assessed at admission by the floor nurse, by the wound care nurse within 24 hours, weekly and as needed. WCN #1 said she documented her skin assessments on a paper log and then transcribed the paper log notes into the residents’ EMRs, either as a skin assessment or a wound assessment, depending on what she saw during her skin assessment. WCN #1 said she documented the wound treatment orders on the wound assessment. WCN #1 said she was familiar with Resident #1. WCN #1 said when she saw Resident #1, she documented her findings on the paper log. WCN #1 said she updated Resident #1’s EMR on 10/23/25. WCN #1 said she obtained physician’s orders for miconazole on 10/16/25 and she did not enter the orders into Resident #1’s EMR until 10/23/25. WCN #1 said since she did not enter the physician’s orders into the EMR timely, the floor nurses were unable to administer the medication to Resident #1 as ordered. WCN #1 said she completed wound care to Resident #4’s both legs on 10/31/25 even though there were no active physician’s orders at that time. She said wound care physician’s orders for Resident #4 were entered on 11/2/25 for the resident’s left leg only. LPN #1 was interviewed on 11/5/25 at 12:26 p.m. LPN #1 said she completed wound care on 11/3/25 for Resident #4’s left leg only as it was the only treatment order listed on the resident’s TAR at that time. LPN #1 said she did not know who completed the wound care for the right leg, noting the bandage was clean, without drainage, and not soiled. LPN #1 said she thought there might have been a physician’s order for the right leg wound scheduled for a different day but she could not find any documentation. LPN #1 said she did not ask WCN #1 about the resident’s right leg wound treatment nor document it. The director of nursing (DON) was interviewed on 11/4/25 at 12:20 p.m. The DON said residents’ skin was assessed at admission by the floor nurse, by the WCN within 24 hours, weekly and as needed. The DON said if a resident came with discharge orders for wound treatment, the floor nurse who admitted the resident did not obtain wound treatment orders, the ADON or another nurse entered the wound treatment orders. The DON was interviewed a second time on 11/5/25 at 1:10 p.m. The DON said all physician’s orders should be entered into the residents’ EMRs as a physician’s order, not in a skin evaluation assessment or wound evaluation assessment. The DON was familiar with Resident #1. The DON said she talked to WCN #1 after Resident #1 was discharged to the hospital and that was when the DON found out WCN #1 did not enter the skin assessment and the physician’s order for miconazole in Resident #1’s EMR until 10/23/25. The DON said WCN #1 should have entered the physician’s order for the miconazole as soon as it was obtained so the floor nurses could administer the medication timely. The DON was familiar with Resident #2. The DON said the resident’s toe wound treatment orders should have been in Resident #2’s EMR as a physician’s order so the floor nurses were aware of the treatment orders and when to provide care. The DON was familiar with Resident #3. The DON said the nursing staff needed to notify the physician when the physician’s order was not followed so the physician could provide further orders if needed. The DON said there were no physician’s orders in place for Resident #4’s wounds when WCN #1 provided treatment on 10/31/25. However, she said WCN #1 documented the treatment in the resident’s progress notes. The DON said as of 11/4/25 (during the survey), the facility had entered physician’s orders into Resident #4’s November 2025 CPO for wound treatment of both legs.

A complaint survey, prompted by #CO2570547 was conducted on 7/28/25 to 7/30/25. No deficiencies were cited.

A complaint survey, prompted by #CO1944328 and Incident #1944320 was conducted on 7/15/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of three sample residents. Resident #1 was admitted on 5/13/25 with diagnoses of metabolic encephalopathy (a change in how the brain works), weakness, difficulty in walking, heart failure and unspecified dementia. On 6/18/25 a nursing staff member documented Resident #1 was wandering, angry and saying he wanted to leave. The facility initiated a care plan for wandering on 6/19/25, however, the care plan did not identify the resident was at risk for elopement, despite the resident indicating he wanted to leave. The facility did not implement any interventions to prevent a potential elopement from the facility for Resident #1. On 6/22/25 Resident #1 was on the phone with a family member and said he was going home. When the family member called the facility to check on the resident, the facility was unable to locate the resident. Resident #1 was found by the police in a soccer field an hour and a half later and transported to the hospital. Resident #1 suffered a laceration (a deep cut) to his head, extensive bruising to his upper extremities, left temple and face, and abrasions (scrapes) to both knees. The resident was transported to the hospital for treatment prior to returning to the facility. Specifically, the facility failed to:- Identify Resident #1 was at risk for elopement; and,-Ensure Resident #1 was provided with the supervision necessary to prevent an elopement. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/15/25, resulting in the deficiency being cited as past noncompliance with a correction date of 6/26/25. I. Elopement incident on 6/22/25On 6/22/25 the facility staff received a phone call from Resident#1's family member who said she was on the phone with the resident and he said he was going home. The facility was unaware the resident had exited the facility. The police found the resident an hour and a half after he was noted as missing. He was found in a soccer field and had extensive bruising and a laceration to his head. Police transported the resident to the hospital. II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #1's elopement incident on 6/22/25 was provided by the nursing home administrator (NHA) on 7/15/25 at 2:05 p.m. The plan documented the following:A. Immediate action On 6/22/25 all staff was educated on the facility’s policy and procedure for elopement. The NHA and the regional director of operations completed a facility audit on 6/24/25 and reviewed the wander risk assessment to determine which residents were high risk for elopement. Once identified, residents’ care plans were updated to prevent residents from eloping. The binder at the front desk was updated to include pictures and information of residents who were high risk for elopement. Signs were placed at the front exit, on visitor elevators and displayed at the reception desk to alert visitors not to assist residents outside, unless approved by a staff member. B. Identification of other residentsCurrent residents in the facility were reviewed and residents who were high risk for elopement were identified. Effective immediately, new admissions to the facility would be assessed for elopement risk and interventions would be initiated to prevent elopement. C. Systemic changesOn 6/22/25 to 6/26/25 the NHA completed in-services to all staff on the facility's elopement policy to include an elopement assessment, updating the care plan and the basics on conducting a search. All new admissions were assessed and care planned for elopement risk if the assessment indicated moderate to high risk elopement. An elopement drill would be conducted once a month to ensure all staff members were aware of what to do when there was an elopement, per the facility policy. D. MonitoringThe NHA or designee would review random residents' elopement risk assessments to ensure they were completed and that residents who identified as high risk had interventions in place. Monitoring would continue for two weeks and then one time a month for three months. The NHA or designee would monitor that elopement drills were completed monthly for the following three months. III. Facility policy and procedureThe Elopement policy and procedure, revised 3/28/24, was provided by the NHA on 7/14/25 at 1:30 p.m. It read in pertinent part, "It is the policy of the facility that staff shall investigate and report all cases of missing residents."If an employee discovers that a resident is missing from the facility, he/she should determine if the resident was out on an authorized leave or pass. If the resident was not authorized to leave, initiate a search of the facility and premises. If the resident was not located, notify the NHA and the director of nursing (DON), the resident's legal representative, the attending physician and law enforcement officials."IV. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 5/13/25, readmitted on 6/23/25 and discharged to the hospital on 7/12/25. According to the July 2025 computerized physician orders (CPO), diagnosis included metabolic encephalopathy, weakness, difficulty in walking, heart failure and unspecified dementia. The 5/20/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The assessment indicated the resident used a wheelchair and a walker. He was dependent on staff for transfers. B. Resident #1's representative's interviewResident #1's representative was interviewed on 7/15/25 at 10:16 a.m. via phone. The resident's representative said she was on the phone with Resident #1 when he said he was going home. She said she heard a visitor speaking to the resident asking if he was able to get back in. She said she immediately called the facility to check on his status. She said the facility was unable to locate Resident #1 and a search was conducted. She said the police found Resident #1 at a soccer field behind the facility and transported him to the hospital for treatment of his injuries. C. Record reviewThe wandering care plan, initiated 6/19/25 and revised 7/4/25, revealed Resident #1 had an acute history of wandering outside of the facility grounds. The interventions included checking the resident for physical comfort needs/pain (initiated 6/19/25), offering emotional and psychological support as needed (initiated 6/19/25), providing and involving the resident in activities directed at the resident’s specific interests (initiated 6/19/25), reorienting and redirecting the resident as needed (initiated 6/19/25), providing one-to-one staff as needed (initiated 6/26/25) and posting a picture/photo of the resident at the front desk to identify elopement risk (initiated 6/27/25). The elopement care plan, initiated 6/23/25 and revised 7/1/25, revealed Resident #1 left the facility unescorted on 6/22/25 and was at risk for further elopement. Interventions included documenting any attempts at elopement, encouraging visits from friends and family, monitoring the resident's whereabouts regularly, offering emotional support, orienting the resident to the environment, placing a photo of Resident #1 at the front desk to identify the elopement risk and providing a one-to-one staff member for safety. The wandering risk assessment, dated 5/13/25, revealed Resident #1 was a low risk for wandering.-However, the facility failed to complete another wander risk assessment on 6/18/25 when Resident #1 was noted to be upset, wandering in the facility and saying he wanted to leave (see progress note below). A nursing progress note, dated 6/18/25 at 3:46 p.m. (four days before the elopement), revealed Resident #1 was wandering, angry and saying he wanted to leave. The nurse and certified nurse aide (CNA) walked with the resident around the nurses station for 40 minutes. The resident was having a hard time maneuvering his walker. The nurse spoke to Resident #1’s representative who was also unable to redirect him. -The facility failed to identify Resident #1's exit seeking behavior prior to his elopement and implement effective interventions to prevent a potential elopement. A nursing progress note, dated 6/22/25 at 9:10 p.m., revealed Resident #1 was last seen at 8:49 p.m. when he was administered medication. He was calm, sitting in a chair in front of the nurses’ station and talking on the phone. At 9:10 p.m. Resident #1's representative called the facility to check in and the resident was noted to be missing. The representative said she was speaking to him on the phone and he told her he was coming home. She said she heard a man asking Resident #1 if he knew how to go back into the facility. The entire facility was searched, including outside areas, by the staff. All other residents were accounted for. The assistant director of nursing (ADON), the DON and the police were notified. A nursing progress note, dated 6/23/25 at 5:56 p.m., revealed Resident #1 had returned from the hospital with extensive bruising to both upper extremities, left temple and face. Abrasions were noted to both knees. Resident #1 was highly confused and a wanderer. Staff was unable to easily redirect him. He was a high fall and elopement risk. He had poor balance and resisted most of his cares and treatments. V. Staff interviewsThe facility’s receptionist was interviewed on 7/15/25 at 12:10 p.m. The receptionist said the facility’s front doors automatically locked at 6:30 p.m. She said a visitor needed to ring the door bell at the front entrance after 6:00 p.m. However, she said anyone was able to exit the facility at any time. She said a receptionist was on duty everyday from 7:00 a.m. to 7:00 p.m. She said at the time of the survey, the facility did not have any wandering residents. She said if a resident was identified as a wander or an elopement risk, their photo and information was posted at the front desk. She said all the staff attended an in-service on the elopement policy following Resident #1's elopement. She said all staff must know where a resident was going or the resident must have a staff member with them when leaving the facility. She said there was a sign out binder for the residents to sign out on pass. CNA #1 was interviewed on 7/15/25 at 12:58 p.m. CNA #1 said Resident #1 always wandered and was exit seeking. She said a CNA was assigned as one-to-one supervision for Resident #1, but she said he did not have one-to-one supervision prior to his elopement. She said he was in an observation room in front of the nurses’ station because he was a high fall risk. She said Resident #1 was very fast and he would be sitting in the common area by the elevators and the next moment he would be gone. She said she was not working the day of the elopement. Registered nurse (RN) #1 was interviewed on 7/15/25 at 1:02 p.m. RN #1 said Resident #1 did not have any wandering or exit seeking behavior that he was aware of. He said Resident #1 was admitted as a high fall risk and always had a low blood pressure. He said Resident #1 was admitted to an observation room across from the nurses’ station because he was very forgetful and was always trying to get out of bed. He said after Resident #1's elopement, an in-service was provided for all staff. The DON was interviewed on 7/15/25 at 3:40 p.m. The DON said she was not aware of the 6/18/25 nurse progress note that indicated Resident #1 was wandering and wanted to leave. She said the staff did not identify Resident #1's exit seeking behavior and no interventions were put into place as far as she knew. She said she did not know Resident #1 was capable of leaving the second floor. She said she was aware that Resident #1 had a lot of behaviors and was a high fall risk, but she did not know he was a wandering risk. She said the staff had a morning huddle but it was not communicated to her that Resident #1 was exit seeking prior to his elopement from the facility on 6/22/25. She said she was not aware that the MDS coordinator had initiated a wandering care plan on 6/19/25. She said there must have been a lack of communication. The NHA was interviewed on 7/15/25 at 4:18 p.m. The NHA said the staff failed to identify Resident #1's behavior on 6/18/25 as exit seeking. She said the staff were more focused on his fall risk and behaviors. She said she did not think Resident #1 knew where the elevator was or how to get outside. She said following his elopement, a plan of correction was put into place to prevent residents from eloping. She said she believed the facility completed a thorough investigation and put measures in place to safeguard residents from elopements. RN #2 was interviewed via phone on 7/15/25 at 4:43 p.m. RN #2 said Resident #1 was sitting in the lobby next to the elevators and he seemed fine (on 6/22/25). She said she had other residents to care for and continued to provide care for the other residents. She said Resident #1's representative called the facility and asked for Resident #1 to be checked on because she was on the phone with him and she thought he may be outside. RN #2 said she did not think Resident #1 was outside but she said she looked for him anyway. She said the staff was unable to locate the resident and the ADON was notified and she notified the DON and the police. RN #2 said Resident #1 was found by the police and transported to the hospital. She said she was not aware of the 6/18/25 nurse progress note regarding the resident wandering and wanting to leave and was not aware Resident #1 was exit seeking. She said there were only interventions for his fall risk prior to the resident’s elopement. She said following the elopement, all staff received an in-service training on the elopement policy, as well as completing risk assessments.

A complaint survey, prompted by #CO39792 and #CO40008 was conducted on 6/23/25. No deficiencies were cited.

A complaint survey, prompted by #CO39197 was conducted on 3/6/25. No deficiencies were cited.

A complaint survey, prompted by #CO38760 and #CO38932 was conducted 1/29/25. No deficiencies were cited.

A complaint survey, prompted by #CO38288 and #CO38418 was conducted on 12/12/24. No deficiencies were cited.