Ahc of Lakewood LLC

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Missing two (2) year smoke detector sensitivity report.2. Cintas did not test all fire alarm devices.NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.. Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding bla.. Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105Records were not available at the time of the survey to document the inspection and testing operation of the fire dampers installed in the facility as required one year after initial insp.. Based on observation and staff interview, it was determined that the facility failed to maintain wiring in accordance with NFPA 101 and NFPA 70.Electrical receptacle in the kitchen next to the sink is needs to be a GFCI receptacle.NFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrica.. Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:Oxygen transfill room - All combustible materials needs to be removed NFPA 99: .11.3.2* Storage for nonflammable gasses greater than 8.5 m3 (300 ft3), but.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1.Semi Annual Hood Inspection | Only 7/20/23 report available for review | no previous report available2.Semi Annual Hood Cleaning | Only 11/9/23 report available for review | no previous report availableNFPA .. Based on observations and records review, it was determined that the facility did not have Fire Alarm out of service guidance in accordance with NFPA 101. Out of Service Fire Alarm Guidance | Does not include verbiage for state notificationNFPA 101 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour.. Based on observations and records review, it was determined that the facility did not have Sprinkler System out of service guidance in accordance with NFPA 101 and NFPA 25Out of service Sprinkler Guidance - Not available at time of surveyNFPA 101, 9.7.6 Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Test.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011) One (1) painted sprinkler head in the IT room. Per NFPA 13 section 3-2.6.3 "Unless applied by the manufacturer, sprinkler sha.. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills are required to be conducted on each shift quarterly; the facility failed to conduct a fire drill on the second shift in the fourth quarter. NFPA 101, 19.7.1.6 Drills shall be conducted quar.. The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of the facility' s general characteristics. The facility is a one-story wood frame structure, approximately 41,000 sq. ft., Type..

A recertification survey was conducted from 12/18/23 to 12/21/23. Seven deficiencies were cited. An Emergency Preparedness survey was conducted from 12/18/23 to 12/21/23. One deficiency was cited. Based on observation, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#242) of five residents reviewed for medication errors of 21 sample residents.Specifically, the facility failed to ensure that Resident #242 was administered the correct dose of insulin by.. Based on observations, interviews and record review, 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 disease and infection in one out of one units.Specifically, the facility failed to:-Ensure an intravenous (IV) adminis.. Based on record review and interview, the facility failed to complete an additional testing exercise of choice in addition to activating its emergency plan. Specifically, the facility failed to conduct an additional full-scale exercise, individual facility based functional exercise, mock disaster drill, table top exercise or workshop in the last .. Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews for three of five certified nurse aides (CNAs) reviewed. Specifically, the facility had not provided inservice educati.. Based on record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for one (#22) of three residents out of 21 sample residents. Specifically, the facility failed to de.. Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#242) resident reviewed for discharge planning out of 21 sample residents. Specifically, the facility failed to ensure the discharge planning process was developed, communicated and documented in Resident #242' s medical rec.. Based on record review and interviews, the facility failed to honor resident choices for two (#22 and #94) of three residents reviewed for showers out of 21 sample residents. Specifically, the facility failed to ensure Resident #22 and Resident #94 received two showers a week and identified on the baseline care plan.Findings include: I. Resid.. Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included the use of an elec..

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/04/2023 and 12/10/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.