24
Inspections
50
Deficiencies
1
Actual Harm or Above
37
Occurrences
April 21, 2026
Last Inspection
S/S D/E/F Potential for harmS/S G Actual harm
The most recent inspection of GLENWOOD SPRINGS HEALTHCARE on record is dated April 21, 2026. Across 24 published inspections, state surveyors cited 50 deficiencies, 1 of which reached actual harm or immediate jeopardy.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
SNF/NF Dual Certification
Administrator
Fleck, Colton
Owner
BLAKE AVENUE OPERATIONS LLC
Phone
(970) 945-5476
Payor Source
Medicare, Medicaid, Private Pay
City
GLENWOOD SPRINGS
ZIP
81601
Inspections & Citations
24 inspections · 50 deficiencies4/21/2026Complaint Survey · ID 22F162-H13 deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO2710062, #CO2793831, Incident #2801718, Incident #2801735, Incident #2801756, Incident #2801780 and Incident #2801784 was completed on 4/20/26 to 4/21/26. Three deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0558Reasonable Accommodations Needs/Preferences▼
Findings
Based on record review and interviews, the facility failed to provide reasonable accommodations for six (#9, #7, #8, #15, #2 and #13) of 10 residents out of 15 sample residents. Specifically, the facility failed to ensure call lights were within reach for Resident #9, Resident #7, Resident #8, Resident #15, Resident #2 and Resident #13. Findings include: I. Facility policy and procedureThe Answering the Call Light policy, revised September 2022, was provided by the nursing home administrator (NHA) on 4/21/26 at 6:48 p.m. The policy read in pertinent part,“Ensure that the call light system is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.”II. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on 4/17/26. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, chronic kidney disease and dysphagia. The minimum data set (MDS) assessment was not completed at the time of the survey. The 4/21/26 at 2:04 p.m. progress note revealed Resident #9 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out 15. B. Resident observations and interviewOn 4/20/26 at 4:22 p.m. Resident #9 was in her room, requesting assistance. Resident #9 lifted up her right hand. Her lifted hand had feces covering her palm and fingers. She requested wipes to clean up with and said she already used her napkin. A soiled napkin was on top of her lunch plate on the bedside table next to her. Her call light was not turned on and it was not accessible. The resident identified that she was lying partially on top of it and could not reach it. The staff were not observed in the hallway or near the resident’s room. At 4:23 p.m. a resident in a room near Resident #9’s room turned their call light on to notify staff that Resident #9 needed assistance. At 4:26 p.m. an unidentified certified nurse aide (CNA) entered Resident #9’s room and closed the door. C. Record reviewThe activities of daily living (ADL) care plan, revised 4/21/26, documented Resident #9 had an ADL self-care performance deficit related to chronic kidney disease. The fall care plan, revised 4/21/26, identified Resident #9 needed a safe environment and prompt response to all requests for assistance. Interventions, initiated 4/21/26, included ensuring the resident had a workable, reachable call light and encouraging her to use the call light for assistance as needed. III. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on 12/23/13 and readmitted on 8/19/25. According to the April 2026 CPO, diagnoses included unspecified sequelae of unspecified cerebrovascular disease, dysarthria (speech disorder) following other cerebrovascular disease, cognitive communication deficit, need for assistance with personal care, muscle weakness, unspecified lack of coordination, other abnormalities of gait and mobility and repeated falls. The 3/25/26 MDS assessment documented Resident #7 had moderate cognitive impaired with a BIMS score of nine out 15. The MDS assessment revealed the resident did not have inattention or disoriented thinking and understood what was said to her. Resident #7 was dependent on staff assistance for bed mobility, toileting, dressing, personal hygiene and surface-to-surface transferring. Resident #7 used a wheelchair for a mobility device. According to the MDS assessment, Resident #7 had unclear speech and difficulty communicating some words. B. Resident observations and interviewOn 4/20/26 at 3:59 p.m. Resident #7 was in her bed. Resident #7 had a distressed look on her face. The resident’s mouth was open, brow furrowed and her eyes were squinting. Her call light cord was hanging on the far corner of a dresser drawer. Resident #7 was not able to reach the cord and indicated that she needed staff assistance. On 4/21/26 at 10:58 a.m. Resident #7 was in bed asleep. Her call light was under a blanket on top of her wheelchair, approximately four feet from her and on the opposite of her bedside dresser. At 1:29 p.m. Resident #7 was awake in her bed. Her call light was on the right side of her, next to her pillow. She reached for the call light and pushed the button to signal for assistance. She shook her head no when asked if her call light was always within her reach. An unidentified CNA entered Resident #7’s room and asked the resident if she needed her brief to be changed and she nodded yes. C. Record reviewThe ADL care plan, revised 9/16/25, documented Resident #7 had an ADL self-care performance deficit related to impaired mobility and a traumatic brain injury (TBI). The care plan directed staff to encourage Resident #7 to use the call light/bell to call for assistance (initiated 1/10/2020). D. Staff interviewCNA #1 was interviewed on 4/21/26 at 2:41p.m. CNA #1 said Resident #7 was able to make her needs known but had difficulty speaking. She said the resident was able to say yes, no, nod and make verbalization sounds. CNA #1 said the resident was able to use her call light and would often push it. She said Resident #7 would sometimes sleep with the call light in her hand.-However, observations revealed Resident #7’s call light was not always consistently within reach of the resident (see observations above). IV. Resident #8A. Observation and interviewOn 4/20/26 at 4:05 p.m Resident #8 was in his wheelchair, next to his bed. Resident #8 said he did not know where his call light was. The resident looked around his bed and found the call light under his bed. He attempted to grab the call light with a reaching device but could not retrieve the call light from the floor independently. He said he tried to keep the call light on his bed but sometimes it would fall on the floor.
Plan of correction · submitted by the facility
F558 Call LightsCorrectionResident #9, 7, 8, 15, 2 and 13, has their call light in reach when they are in their room. Identification:Residents currently residing within the facility who are not independent are at potential risk. Systemic:All staff have been in-serviced making sure that residents have placement of call lights within reach when they are in bed and in the room. It was also included that when you are in and out of the room providing care to check and make sure that the call light is still in place and easily accessible to the Resident. This in-service was provided by the DON (director of nursing)/designee and will be completed by the date of compliance. NHA (nursing home administrator)/designee will perform call light observation audits 3 to 5 times per week for 90 days, to include different shifts and hallways. Audits will be documented on paper using an audit tool. All identified issues will be addressed immediately. Monitoring:NHA or designee will report to the quality assurance performance improvement (QAPI) committee regarding compliance at least monthly for 90 days or until substantial compliance is determined by the committee.
0609Reporting of Alleged Violations▼
Findings
Based on record review and interviews, the facility failed to timely report an allegation of abuse involving two (#1 and #2) of six residents reviewed for abuse out of 15 sample residents. Specifically, the facility failed to:-Timely report an allegation of physical abuse by Resident #2 towards Resident #1; and,-Timely report an allegation of verbal abuse by Resident #1 towards Resident #2. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 4/21/26 at 6:48 p.m. It read in pertinent part, “All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. “If abuse, neglect, exploitation, or misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and two other officials according to state law. “The administrator or other individuals making the allegation immediately reports his or her suspicion to the following person or agencies: The state licensing/certification agencies responsible for surveying/licensings of facility; the local/state ombudsman; the residents’ representative; adult protective services; law enforcement officials; and, facility medical director. “Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions are needed for the protection of residents.”According to the policy, the facility should report within two hours if the allegation involved abuse or resulted in serious bodily injury or within 24 hours of an allegation that did not involve abuse or resulted in serious bodily injury. II. Allegation of physical abuse by Resident #2 towards Resident #1 Record review and interviews during the survey (see below) identified a 1/30/26 allegation of verbal abuse involving Resident #1 and Resident #2. The allegation was not reported to the State Agency until 2/2/26, three days after the incident occurred. A. Facility investigationA 1/30/26 physical abuse investigation involving Resident #1 and Resident #2 was provided by the NHA on 4/21/26 at approximately 9:30 a.m. The investigation included the incident report to the State Agency, related progress notes (see below) and a witness statement. The incident report identified the incident occurred on 1/30/26 at 9:37 p.m. and the incident report was submitted to the State Agency on 2/2/26 at 6:42 p.m. According to the incident report, the initial report was due on 1/31/26 at 9:37 p.m. The initial report was marked late. The initial report documented that on 2/2/26 at 5:00 p.m the nurse management team was made aware of an incident between Resident #1 and Resident #2 that occurred on 1/30/26 at approximately 9:00 p.m. The investigation identified a certified nurse aide (CNA) heard arguing in the room of Resident #1 and Resident #2. The CNA entered the residents’ room and discovered one of the residents (Resident #2) hitting another resident (Resident #1). The CNA intervened and separated the residents. The CNA alleged that she reported it to the nurse but the nurse did not report it to the facility management. The facility notified police, conducted a head-to-toe assessment, attempted to change resident rooms, and began conducting resident abuse surveys on 2/2/26. A 2/2/26 witness statement, included in the 2/2/26 investigation of the incident and documented by licensed practical nurse (LPN) #1, identified that on 1/30/26 she heard yelling in the hallway. CNA #5 told LPN #1 that Resident #2 was yelling at Resident #1. CNA #5 separated the residents and the yelling stopped. According to the witness statement, CNA #5 did not inform LPN #1 that there was physical hitting between the residents during the argument. The statement documented CNAs were instructed to report any additional yelling so proper protocols could be initiated. The facility investigation documented the alleged victim (Resident #1) did not feel threatened or unsafe and was refusing to change rooms. The facility substantiated the allegation. A. Resident #1 (alleged victim)
1. Resident statusResident #1, age less than 65, was admitted on 11/18/24. According to the April 2026 computerized physician orders (CPO), diagnoses included anoxic brain damage, personal history of traumatic brain injury, insomnia due to other mental disorders, restlessness and agitation, chronic systolic congestive heart failure and major depressive disorder, recurrent. The 2/19/26 minimum data set (MDS) assessment identified Resident #1 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out 15. The MDS assessment indicated Resident #1 had lower extremity impairment on both sides with no upper extremity impairment. According to the MDS assessment, Resident #1 had verbal behavioral symptoms directed toward others. 2. Record reviewA 2/2/26 nursing note documented LPN #2 received a statement on 2/2/26 from an overnight CNA indicting another resident (Resident #2) punched Resident #1 and CNA #2 had intervened by removing the other resident away from Resident #1. According to the note, LPN #2 interviewed Resident #1. Resident #1 said he was yelling and cursing at Resident #2 and Resident #2 punched him three times in the arm before the CNA entered the room and intervened. Resident #1 said he was not scared of the other resident and did not want to move rooms. The note indicated Resident #1 would inform staff immediately if he felt uncomfortable or wanted to move rooms. -Review of progress notes did not reveal documentation of the resident-to-resident altercation on 1/30/26. B. Resident #2 (alleged assailant)
1. Resident statusResident #2, age greater than 65, was admitted on 5/18/17. According to the April 2026 CPO, diagnoses included legal blindness, hemiplegia with hemiparesis (motor impairment on one side) following cerebral infarction (stroke) affecting right dominant side, muscle weakness and personal history of malignant neoplasm (cancerous tumor) of the brain. The 2/7/26 MDS assessment identified Resident #2 was cognitively intact with a BIMS score of 15 out 15. The MDS assessment indicated the resident’s vision was severely impaired. He had upper and lower extremity impairment on one side. He used a walker and a wheelchair for mobility. According to the MDS assessment, Resident #2 did not have physical or verbal behavioral symptoms directed toward others. 2. Resident interview Resident #2 was interviewed on 4/21/26 at 10:50 a.m. Resident #2 said he did not get along with Resident #1. He said they had gotten into a physical fight. He said they were not offered to change rooms after the fight. He said Resident #1 would tell him that he would kick his (expletive) and was very rude to him. He said he just tried to ignore Resident #1 until he was moved to another room. 3. Record reviewA 2/2/26 at 5:38 p.m. nursing note, documented by the former director of nursing identified Resident #2 was involved in a resident-to-resident altercation. According to the note, a resident (Resident #1) made a statement that Resident #2 did not like so Resident #2 hit Resident #1 in the upper right arm three times.-The note did not identify when the altercation occurred. A 2/2/26 at 6:17 p.m. nursing note, documented by LPN #2, identified she received a statement from the overnight shift CNA that on 1/30/26 at approximately 9:00 p.m. Resident #2 became aggressive with another resident and punched the resident (Resident #1) three times. Resident #2 said Resident #1 kept cursing at him and threatening to hit him so Resident #2 approached Resident #1 and hit him three timesbefore the CNA entered the room and removed him from Resident #1. According to the note, there were no injuries to either resident. The note documented LPN #2 educated Resident #2 that the behavior was inappropriate and he could not put his hands on other residents. III. Allegation of verbal abuse between Resident #1 and Resident #2Record review and interviews during the survey (see below) identified a 2/13/26 allegation of verbal abuse involving Resident #1 and Resident #2 which was not reported timely to the State Agency. An email, provided by the NHA on 4/22/26 at 2:49 p.m., documented the facility reported the 2/13/26 allegation of potential verbal abuse to the State Agency on 4/21/26 at 7:39 p.m. (after the survey exit). A. Resident #1 (alleged assailant) 1. Record reviewThe 2/13/26 behavior note documented LPN #2 was walking past Resident #1’s room when she heard him yelling aggressively and inappropriately at his roommate (Resident #2). The note documented Resident #1 told Resident #2 “I hate you,” “shut your stupid mouth” and "I will (expletive) you up." According to the note, LPN #2 entered the room and told Resident #1 that he was being inappropriate. Resident #1 told LPN #2 that he hated Resident #2 and did not want to be in the room. The note documented LPN #2 offered to change his room and Resident #1 agreed. The note documented LPN #2 would discuss the room change with the interdisciplinary team and notify the resident’s representative. The behavior care plan, initiated on 4/20/26 (during survey), documented Resident #1 had the potential to be verbally aggressive. Interventions, dated 4/20/26, identified staff should analyze key times, places, circumstances, triggers and what de-escalated Resident #1’s behavior and document accordingly, ensuring his needs were being promptly met to reduce risk of agitation and giving him as many choices as possible about care and activities. According to the care plan, staff should intervene before his agitation escalated by directing him away from the source of distress and calmly engaging him in conversation. 2. Resident observationObservations on 4/20/26 and 4/21/26 identified Resident #1 and Resident #2 no longer shared the same room. B. Resident #2 (alleged victim)
1. Record reviewThe behavior care plan, initiated 4/20/26, documented Resident #2 had the potential to be physically aggressive. Interventions, initiated 4/20/26, included administering medications as ordered and monitoring and documenting for side effects and effectiveness; analyzing time of day, places, circumstances, triggers and what de-escalated behavior and documenting; assessing and addressing contributory sensory deficits; offering the resident as many choices as possible about care and activities; modifying the resident’s environment by adjusting room temperature, comfort level, reducing noise, dimming lights, placing familiar objects in his room and keeping his door closed; monitoring for and anticipating the resident’s needs, such as food, toileting, comfort level, body positioning and pain; providing physical and verbal cues to alleviate anxiety giving positive feedback; assessing verbalization for source of agitation; assisting the resident to set goals for more pleasant behavior and encouraging him to seek out staff members when agitated. According to the care plan, Resident #2 was provided education to notify staff when he was agitated with other residents. The care plan documented a room change was offered to Resident #2 but he declined to move. IV. Staff interviewsThe NHA and the director of nursing (DON) were interviewed together on 5/21/26 at5:27 p.m. The NHA said physical abuse could be anything physical in nature or impeded on a resident’s personal space that created a discomfort, an unsafe environment or safety risk or actual harm. He said neglect could also be a form of physical abuse. The NHA said verbal abuse could be demeaning and/or threatening language that could make a resident feel discomfort, undignified and/or unsafe. He said threatening language could also be a form of physical abuse. The NHA said he was the facility’s abuse coordinator. He said when he received a report of a potential abuse allegation, whether written or verbal, he would start building the investigation by identifying who was involved and who potentially witnessed the incident that led to the allegation. The NHA said he would conduct interviews identifying how the resident(s) felt, if they felt safe, and looked to see if a room move would be appropriate. He said he would report the allegation to the State Agency and all other appropriate parties. He said the facility would implement frequent checks on the resident, identify if there were any changes to their baseline behaviors, update their care plans and ensure they were safe. The NHA said the 1/30/26 incident between Resident #1 and Resident #2 was substantiated that it occurred. He said the incident began as an argument that then escalated into a physical altercation. He said Resident #2 was punching Resident #1 but Resident #1 brushed it off and said it did not hurt. He said Resident #1 did not want to change rooms but he eventually moved to another room. The NHA said the resident-to-resident physical abuse altercation between Resident #1 and Resident #2 should have been submitted within 24 hours of the incident and there was some confusion on the timeline of the events. He said the administration was not notified of the 1/30/26 incident right after it occurred. The NHA said the former NHA made the initial report to the State Agency after management was notified of the incident. The NHA said he was not made aware of the 2/13/26 verbal altercation between Resident #1 and Resident #2 that was identified in Resident #1’s 2/13/26 nurse note, therefore he did not report it to the State Agency. He said he should have been notified right away of the incident so it was reported and investigated timely. He said there should have been a heightened level of sensitivity and timely reporting of any incidents between Resident #1 and Resident #2 because the residents had just had a punching altercation a couple weeks prior to the verbal altercation. He said he was aware that Resident #1 moved to another room but he believed it was because there was a need to accommodate room changes for other residents and Resident #1 was asked again if he wanted to move and he agreed. The DON said she had heard there was a fight between Resident #1 and Resident #2 (on 1/30/26), but she was a floor nurse at the time and she was not the DON. She said she was not aware of all the circumstances of the incident. The NHA and the DON said staff received frequent abuse training with online modules. The NHA said the facility would implement an abuse performance improvement plan that included increased staff training. The DON and the NHA said the facility had scheduled an all staff in-service on 4/22/26 and they would review the protocol for reporting abuse and the performance improvement plan. V. Facility follow upA performance improvement plan was provided by the NHA on 4/21/26 at 6:46 p.m. The performance improvement plan identified the improvement plan was initiated on 4/21/26 (during the survey) to address the concern that not all staff were aware of the importance of reporting abuse/neglect immediately. The plan included resident interviews to identify if there were additional resident concerns on abuse, education to all staff and the interdisciplinary team (IDT) regarding the definitions of abuse, federal and state reporting requirements and expectations to immediately report potential abuse to the NHA. The performance improvement plan identified the facility would implement an abuse allegation checklist and leadership would review the 24-hour communication log five days a week to ensure all unreported incidents of abuse were identified.
Plan of correction · submitted by the facility
The facility acknowledges the findings related to F609 and has implemented corrective actions to ensure compliance with reporting requirements. Safeguard MeasuresThe alleged violations occurred on 1-30-2026 and a second occurrence took place on 2-13-2026. The incidents involved the same two residents. The altercations were reported to the appropriate state agency and law enforcement, for both incidents. The residents were assessed and appropriate interventions were implemented to ensure safety and well-being. Interventions included:Notifying appropriate staff, family, and policeInterviewing residents to confirm their well-beingOffering to move roomsMonitor behavior and social integrations for changes due to the reported incidentResident #2 was moved to a new room three days after the 2-13-26 incident. The timing of the move was guided by input from family. It was identified that all residents have the potential to be affected by events in the building. A representative sample of the residents were surveyed to identify any unreported conditions of safety, dignity, neglect or abuse. No additional concerns were identified. It is also noted that education in abuse reporting was needed. Staff EducationThe following training was conducted to ensure appropriate identification, investigation and reporting are followed. Training included:The facility provided training on 4/21/2026 to the IDT (interdisciplinary team) related to abuse investigation, timeliness, and reporting. Internal training modules were sent on 4/21/2026 for all employees and included abuse awareness, and reporting. All staff meeting, on 4/22/2026, also provided training in abuse identification and reporting. System ImprovementsThe Administrator will audit all grievances, and allegations of abuse for four weeks beginning on 4-22-2026, then monthly for two months to ensure timely reporting. Results will be reviewed in quality assurance performance improvement (QAPI) meetings for the next two months. Corrective actions will be taken as needed. A Performance Improvement Plan has been implemented and includes:Training IDT and StaffConduct resident interviews. A representative sample of the resident population is who will be interviewed. Notification of abuse incidents also directed to clinical nurse resourceConduct review of 24-hour report for unreported incidents. Corrective action to be implemented.
0689Free of Accident Hazards/Supervision/Devices▼
Findings
Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#7) of three residents reviewed for accident hazards out of 15 sample residents. Specifically, the facility failed to ensure staff utilized a mechanical lift, as was care planned, when transferring Resident #7 from her wheelchair to her bed. Findings include: I. Facility policy and procedure “The Lifting Machine, Using a Mechanical Lift policy, revised July 2017, was provided by the nursing home administrator (NHA) on 4/21/26 at 6:48 p.m. The policy read in pertinent part, “The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions."At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift."Mechanical lifts may be used for tasks the require lifting a resident from the floor, transferring a resident from bed to chair, lateral transfers, lifting limbs and toileting or bathing or repositioning.“Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility.“Before using a lifting device, assess the resident's current condition, including physical. Determine if the resident's weight and medical condition are appropriate for the use of a lift.”II. Observation and staff interview On 4/21/26 at 12:30 p.m. Resident #7 was observed being wheeled into the resident’s room by certified nurse aide (CNA) #2. CNA #2 left the room and left the resident with CNA #1, who was already in the room, and CNA#1 shut the door. At 12:40 p.m. CNA #1 opened the resident’s door and exited the room carrying a bag of soiled linens. Resident #7 was observed lying on her bed.-However, CNA #1 was the only staff member present in the resident’s room at the time of the resident’s transfer. Additionally, there was no mechanical lift observed in the resident’s room or in the vicinity outside the resident’s room. CNA #1 was immediately interviewed upon exiting Resident #7’s room (at 12:40 p.m.) CNA #1 said she used a mechanical lift to transfer the resident into bed. She said CNA #2 had assisted her. When prompted, CNA #1 said Resident #1 used the mechanical lift as needed and sometimes she was just a two-person transfer. She said CNA #2 assisted her after lunch to get the resident into bed without the use of the mechanical lift. She said she did use the mechanical lift to transfer Resident #7 before lunch. -However, CNA #2 did not remain in the room to assist with the transfer after wheeling the resident’s wheelchair to her room after lunch (see observation above). III. Resident #7A. Resident statusResident #7, age 71, was admitted on 8/19/25. According to the April 2026 computerized physician orders (CPO), diagnoses included cerebrovascular disease, other symptoms and signs involving musculoskeletal system, repeated falls and traumatic brain injury. The 3/20/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. She required maximum assistance with activities of daily living (ADL). The MDS assessment indicated the resident was a high fall risk and required a mechanical lift for all transfers. B. Record Review The ADL care plan for mobility and transfers, revised 11/12/25 revealed Resident #7 used the wheelchair and was able to self propel at times. The resident did not ambulate and she required a hoyer lift (mechanical lift) for all transfers. Review of Resident #7’s April 2026 CPO revealed the following physician’s order: Mechanical lift for all transfers, ordered 1/20/26. The physical therapy note, dated 1/16/26, revealed Resident #7 was non-ambulatory and demonstrated severe mobility limitations. It was recommended the nursing staff utilize the hoyer lift (mechanical lift) to ensure safety. The resident exhibited impulsive and unsafe behaviors, including intentionally lowering herself from the wheelchair and the bed, resulting in a high risk for injury. Due to impaired safety awareness, dependence for mobility and inability to perform functional transfers, mechanical lift use was medically necessary to reduce risk of injury to both the resident and the nursing staff. IV. Staff interviews CNA #3 was interviewed on 4/21/26 at 1:15 p.m. CNA #3 said he assisted CNA #1 with using a mechanical lift to transfer Resident #7 today (4/21/26) before lunch. He said his resident assignment list documented what residents needed, a mechanical lift or just a one- or two-person transfer. He said he misplaced the assignment sheet and was not sure if Resident #7 was a lift or not off the top of his head. He said he would check with other CNAs to find out. The director of rehabilitation was interviewed on 4/21/26 at 1:30 p.m. The director of rehabilitation said Resident #7 used the mechanical lift for all transfers. She said the resident was evaluated by the physical therapist back in May 2025 and it was recommended the resident use the mechanical lift for safety concerns. She said the care staff were educated on how to use the mechanical lift and the resident’s care plan reflected the use of the mechanical lift. She said there was another physical therapy evaluation completed this year (2026) with the same recommendations. CNA #4 was interviewed on 4/21/26 at 2:10 p.m. CNA #4 said Resident #7 used a mechanical lift for all transfers. She said as of today (4/21/26), the facility would be implementing a white board in the residents’ rooms to write down how to transfer the residents. She said the transfer information was on the residents’ Kardex (a tool utilized to provide consistent care) but not all staff looked at the Kardex. She said if the mechanical lift was not used when transferring Resident #7, it would be dangerous for staff and the resident could be harmed. The director of nursing (DON) was interviewed on 4/21/26 at 5:10 p.m. The DON said she thought Resident #7 used a mechanical lift at times and was a two-person transfer at other times. She said she was not sure, but she said a mechanical lift was used for safety to transfer a resident from bed to chair or chair to bed. She said she had not educated staff on the use of a mechanical lift but implemented the training today (4/21/26) after she was made aware of the concerns regarding Resident #7’s transfers from staff. She said a mechanical lift was safer for the resident versus a two-person transfer without the mechanical lift. She said there was a potential that staff could drop the resident or cause harm without the use of the mechanical lift during transfers. The NHA was interviewed on 4/21/26 at 5:27 p.m. The NHA said the facility started a performance improvement plan (PIP) as of today (4/21/26), which included staff training on mechanical lifts and a full-house audit of residents who used a mechanical lift. The NHA said the PIP would be implemented to start immediately for the safety of residents and staff. V. Facility follow-up On 4/22/26 at 11:58 a.m. (after the survey exit) the NHA provided additional information which included documentation of an in-service to care staff to reinforce safe transfer practices and proper use of resident care information on the Kardex. Education was completed on 4/21/26 with eight direct care staff members.
Plan of correction · submitted by the facility
F689Correction:Resident #7 is currently being transferred via Hoyer lift with two staff assist as per their care plan. The C.N.A. (certified nurse aide) who performed the one assist transfer on resident #7 was counseled by the ADON (assistant director of nursing) and refused to sign the education. She has chosen to no longer be employed by the facility. Identification:Residents currently residing in the facility who are transferred via Hoyer lift are at potential risk. Residents currently residing in the facility have been reviewed by Interdisciplinary Team (IDT) to identify residents requiring 2-person staff assistance for transfers. Their care plans and Kardex’s have been updated to reflect their transfer status. This was completed on 4/30/26. Systemic:Nursing Staff and Therapy Staff have been Educated on the proper use of facility lifts and how much assistance to use when utilizing the lifts and where to find the information for how much assistance to utilize, i.e. Care Plans, Kardex. Staff on these lifts this was completed by the DON (director of nursing)/ Designee. Staff are to complete this prior to date of compliance or before their next scheduled shift after date of compliance. Onboarding materials will include education on the proper use of facility lifts and how much assistance to use when utilizing the lifts. to ensure safe transferring practices are included in orientation on all nursing and therapy staff prior to them working independently on the floor. IDT reviews the 24-hour report for any changes in resident conditions, any new admissions/ Readmissions. Any residents identified with changes in transfer status will be referred to therapy to ensure that the facility has identified the appropriate transfer technique being used for the safety of the residents. Communication will be made through the care plans and Kardex as needed. This will be documented on Daily Clinical Board. Monitoring:DNS (director of nursing services) or designees are observing resident transfers randomly to monitor safe transfer practices and provide education as needed. This will be completed at various times of the day and evening shifts 3x weekly x 1mon then 6 random observations monthly for the next 2 months. The DON/designee will keep this audit documented on a paper form. The results of her audit will be presented to QAPI committee to ensure that compliance is maintained.
4/21/2026Licensure Complaint Survey · ID 22F164-H1No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A survey with #CO2710063 was completed on 4/20/26 to 4/21/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9999Final ObservationsSurveyor note▼
Findings
THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 5.7.4 ACCIDENT PREVENTION AND ATTENTIONThe facility shall:A) Investigate all causes of accidents;B) Monitor the resident's response to the accident and obtain a physical and/or mental health evaluation from a practitioner, if needed;C) Identify all residents at high risk for accidents and develop an individualized care plan for each of them to prevent future accidents; andD) Evaluate and revise the plan as needed.
Plan of correction
The state did not require a plan of correction for this citation.
8/19/2025Complaint Survey · ID 1D1BE2-H1No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO2568715 and #CO2593350 was conducted on 8/19/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
2/19/2025Revisit: Recertification Survey · ID HEHF22No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.
Plan of correction
The state did not require a plan of correction for this citation.
12/13/2024Revisit: Complaint, Recertification Survey · ID HEHF12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 12/13/24 for all previous deficiencies cited on 10/17/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
11/13/2024Recertification Survey · ID HEHF219 deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
This tag is informational only and represents the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a one-story wood-framed structure, Type V (111), construction; there is a partial basement used for support services only and is not used by residents. The basement has an exterior exit at the ground level. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinkled. The facility was constructed in 1960 and is licensed for 54 beds. The facility staffing is on two (2) twelve-hour (12) shifts. This re-certification survey conducted on November 13, 2024, was for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies," NFPA 99, Health Care Facilities Code, and all referenced standards. The deficiencies cited were discussed with the Administrator and Director of Maintenance during the survey, and the exit conference. The Administrator reported the daily census to 39 residents on the survey day.
Plan of correction
The state did not require a plan of correction for this citation.
0211Means of Egress - GeneralS/S E▼
Findings
Through observation during the survey, it was determined that the facility failed to maintain doors in accordance with NFPA 101. This was evidenced by:1.400 hall exterior delayed egress door is encroaching on the egress pathway2.100 hall exterior egress door does not open fully to a 90-degreeNFPA 101 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101 19.7.3 Maintenance of Means of Egress. 19.7.3.1 Proper maintenance shall be provided to ensure the dependability of the method of evacuation selected. 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 facility maintenance director during the exit conference.
Plan of correction · submitted by the facility
It was determined that the facility failed to maintain doors in accordance with NFPA 101. This was evidenced by: 400 hall exterior delayed egress door is encroaching on the egress pathway; 100 hall exterior egress door does not open fully to a 90-degree. The alleged deficient practice has the potential to affect residents, staff, and visitors of the entire facility. An audit of the entire building to find any other: hall exterior delayed egress door is encroaching on the egress pathway hall exterior egress door does not open fully to a 90-degree This was completed on 11/13/24 and no other areas have been identified at this time. The repair of hall exterior delayed egress door is encroaching on the egress pathway, will be repaired by the DPO by switching the hinge side of interior door to the right, and contacting Sterling Communication to reinstall mag-lock door mechanism to the exterior door which will be completed by 1/12/25 to meet the compliance date of 1/12/25 The hall exterior egress door does not open fully to a 90-degree the swing arm has been adjusted so the door can completely open 90 degrees by the DPO which has been completed on 12/6/24 to meet the compliance date of 1/12/25 Measures that were put into place to keep this alleged deficiency from happening again is that the Maintenance Director/ Designee will perform weekly audits on the hall exterior egress doors weekly for one month and then will be placed on a monthly audit x 3 months. The maintenance director was educated on this tag. This deficiency was reviewed at Q.A. on 11/21/24 and our safety committee on 11/24/24 and will be ongoing for three months at monthly QA for purposes of quality assurance and performance improvement.
0222Egress DoorsS/S D▼
Findings
Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1. 100 hall exterior egress door missing delayed egress signageNFPA 101 19.2.2.2.4Doors 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:(2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. NFPA 101 7.2.1.6.1.1(4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:PUSH UNTIL ALARM SOUNDSDOOR CAN BE OPENED IN 15 SECONDSThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient item(s) were discussed with the maintenance team at the exit conference.
Plan of correction · submitted by the facility
Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 100 hall exterior egress door missing delayed egress signage the deficient practice has the potential to affect residents, staff, visitors within the entire facility. An audit of the entire building to find any other doors missing required delayed egress signage was done on 11/13/24 and no other areas have been identified at this time. The installation of the egress signage was performed by the DPO and was completed on 11/29/24 to meet the compliance date of 1/12/25 Measures that were put into place to keep this alleged deficiency from happening again is Maintenance Director/ Designee will perform weekly audits on the door missing delayed egress signage for one month and then will be placed on a monthly audit x 3 months. The maintenance director was educated on this tag. This deficiency was reviewed at Q.A. on 11/21/24 and our safety committee on 11/24/24 and will be ongoing for three months at monthly QA for purposes of quality assurance and performance improvement.
0311Vertical Openings - EnclosureS/S D▼
Findings
Based on observation, it was determined that the facility failed to arrange and maintain the vertical openings in accordance with Life Safety Code Section 19.3.11.laundry chute is not protected19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. Deficient item(s) were discussed with the maintenance team at the exit conference.
Plan of correction · submitted by the facility
It was determined that the facility failed to arrange and maintain the vertical openings in accordance with Life Safety Code Section 19.3.1. The alleged deficient practice has the potential to affect residents, staff, visitors within the smoke compartment An audit of the entire building to find any other laundry chutes not operating correctly 11/13/24 no other areas have been identified at this time. The repair of the laundry chute will be performed by The DPO and will be completed by 1/12/25 to meet the compliance date of 1/12/25 Measures that were put into place to keep this alleged deficiency from happening again is that the Maintenance Director/ Designee will perform weekly audits on the laundry chute for one month and then will be placed on a monthly audit x 3 months. The maintenance director was educated on this tag. This alleged deficiency was reviewed at Q.A. on 11/21/24 and our safety committee on 11/24/24 and will be ongoing for three months at monthly QA for purposes of quality assurance and performance improvement.
0364Corridor - OpeningsS/S D▼
Findings
Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1. 100 wings transfer grill installed in corridor ceiling needs to be removedNFPA 101 19.3.6.4.1 Transfer grilles, regardless of whether they are protected by fusible link–operated dampers, shall not be used in corridor walls or doors. This deficiency could affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.
Plan of correction · submitted by the facility
It was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 100 wings transfer grill installed in corridor ceiling needs to be removed the alleged deficient practice has the potential to affect residents, staff, visitors within the smoke compartment. An audit of the entire building to find any other transfer grill installed in corridor ceiling was done on 11/13/24 no other areas have been identified at this time. The 100 wings transfer grill will be uninstalled in corridor ceiling and will be patched with 5/8 fire rated dry wall and will be completed by 1/12/25 to meet the compliance date of 1/12/25. Measures that were put into place to keep this alleged deficiency from happening again is that Maintenance Director/ Designee will perform weekly audits on the corridor ceiling weekly for one month and then will be placed on a monthly audit x 3 months. The maintenance director was educated on this tag. This alleged deficiency was reviewed at Q.A. on 11/21/24 and our safety committee on 11/24/24 and will be ongoing for three months at monthly QA for purposes of quality assurance and performance improvement.
0522HVAC - Any Heating DeviceS/S F▼
Findings
Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1.need to address storage of items on heaters in all rooms19.5.2 Heating, Ventilating, and Air-Conditioning. 19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 19.5.2.2.19.5.2.2* Any heating device, other than a central heating plant, shall be designed and installed so that combustible material cannot be ignited by the device or its appurtenances, and the following requirements also shall apply:(1)If fuel-fired, such heating devices shall comply with the following:(a)They shall be chimney connected or vent connected.(b)They shall take air for combustion directly from the outside.(c)They shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area.(2)Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure. 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 facility maintenance director during the exit conference.
Plan of correction · submitted by the facility
It was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: need to address storage of items on heaters in all rooms The alleged deficient practice has the potential to affect residents, staff, visitors of the entire facility. An audit of the entire building to find any other storage of items on heaters was done on 11/13/24. no other areas have been identified at this time. The removal of storage of items on heaters was performed by the DPO and was completed on 11/29/24 to meet the compliance date of 1/12/25. Measures that were put into place to keep this alleged deficiency from happening again is that the storage of items on heaters was repaired on 11/19/24. Maintenance Director/ Designee will perform weekly audits on storage of items on heaters for one month and then will be placed on a monthly audit x 3 months. The maintenance director was educated on this tag. This alleged deficiency was reviewed at Q.A. on 11/21/24 and our safety committee on 11/24/24 and will be ongoing for three months at monthly QA for purposes of quality assurance and performance improvement.
0711Evacuation and Relocation PlanS/S D▼
Findings
Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1. Fire Safety Plan (101 19.7.2.2): Not available per NFPA 101 requirementsNFPA 101 19.7.1 Evacuation and Relocation Plan and Fire Drills. 19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. NFPA 101 19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:(1)Use of alarms(2)Transmission of alarms to fire department(3)Emergency phone call to fire department(4)Response to alarms(5)Isolation of fire(6)Evacuation of immediate area(7)Evacuation of smoke compartment(8)Preparation of floors and building for evacuation(9)Extinguishment of fireNFPA 101 This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.
Plan of correction · submitted by the facility
It was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: Fire Safety Plan (101 19.7.2.2): Not available per NFPA 101 requirements The alleged deficient practice has the potential to affect residents, staff, visitors within the entire facility. An audit of the entire building to find any other missing fire policy and emergency plan was done on 11/13/24 no other areas have been identified at this time. The replacement of the fire policy and emergency plan was performed by the DPO and was completed on 11/29/24 to meet the compliance date of 1/12/25 Measures that were put into place to keep this alleged deficiency from happening again is the Maintenance Director/ Designee will perform weekly audits on the fire policy and emergency plan placement for one month and then will be placed on a monthly audit x 3 months. The maintenance director was educated on this tag. This deficiency was reviewed at Q.A. on 11/21/24 and our safety committee on 11/24/24 and will be ongoing for three months at monthly QA for purposes of quality assurance and performance improvement.
0914Electrical Systems - Maintenance and TestingS/S F▼
Findings
Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1. Receptacle Testing (99 6.3.4.1): Partially done, not completeNFPA 996.3.4.1.1Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3Receptacles not listed as hospital-grade at patient bed locations and in locations where deep sedation or general anesthesia is administered shall be tested at intervals not exceeding 12 months. NFPA 996.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.
Plan of correction · submitted by the facility
It was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by: Receptacle Testing (99 6.3.4.1): Partially done, not complete the alleged deficient practice has the potential to affect residents, staff, visitors of the entire facility An audit of the documentation to find any other receptacle testing incomplete was done on 11/13/24 no other areas have been identified at this time. The completion of the receptacle testing was performed by the DPO and was completed on 11/29/24 to meet the compliance date of 1/12/25. Measures that were put into place to keep this alleged deficiency from happening again the Maintenance Director/ Designee will perform weekly audits on the documentation of the receptacle testing for one month and then will be placed on a monthly audit x 3 months. Maintenance director was educated on this tag. This alleged deficiency was reviewed at Q.A. on 11/21/24 and our safety committee on 11/24/24 and will be ongoing for three months at monthly QA for purposes of quality assurance and performance improvement.
0923Gas Equipment - Cylinder and Container StoragS/S D▼
Findings
Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99. This was evidenced by:1. Oxygen Transfilling containers need proper labeling of empty and full containersNFPA 99 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. NFPA 99 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.
Plan of correction · submitted by the facility
It was determined that the facility failed to meet the protection requirements in accordance with NFPA 99. This was evidenced by: Oxygen Transfilling containers need proper labeling of empty and full containers. The alleged deficient practice has the potential to affect residents, staff, and visitors within the entire facility. An audit of the entire building to find any other containers need proper labeling of empty and full containers 11/13/24 no other areas have been identified at this time. The need for proper labeling of empty and full containers will be performed by the DPO by adding signage to the walls and will be completed by 1/12/25 to meet the compliance date of 1/12/25 Measures that were put into place to keep this alleged deficiency from happening again is that the Maintenance Director/ Designee will perform weekly audits on the containers need proper labeling of empty and full containers weekly for one month and then will be placed on a monthly audit x 3 months. The maintenance director was educated on this tag. This alleged deficiency was reviewed at Q.A. on 11/21/24 and our safety committee on 11/24/24 and will be ongoing for three months at monthly QA for purposes of quality assurance and performance improvement.
0927Gas Equipment - Transfilling CylindersS/S D▼
Findings
Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1. The oxygen trans filling room needs mechanical ventilation 0-12" from the floor. NFPA 99 9.3.7.4 Transfilling area shall be provided with ventilation in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code. NFPA 55 6.15.7.26.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor. This deficiency could affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.
Plan of correction · submitted by the facility
It was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by: The oxygen trans filling room needs mechanical ventilation 0-12" from the floor. The alleged deficient practice has the potential to affect residents, staff, and visitors within the smoke compartment. An audit of the entire building to find any other Ventilation 12 inches from floor in the oxygen transfer room and proper labeling empty and full oxygen was done on 11/13/24 no other areas have been identified at this time. Ventilation was provided 12 inches from floor in the oxygen transfer room via duct work and will be performed by the DPO and will be completed by 12/20/24 to meet the compliance date of 1/12/25. Measures that were put into place to keep this alleged deficiency from happening again is that the Maintenance Director/ Designee will perform weekly audits on the ventilation in the oxygen transfer room weekly for one month and then will be placed on a monthly audit x 3 months. The maintenance director was educated on this tag. This alleged deficiency was reviewed at Q.A. on 11/21/24 and our safety committee on 11/24/24 and will be ongoing for three months at monthly QA for purposes of quality assurance and performance improvement
10/17/2024Complaint, Recertification Survey · ID HEHF119 deficiencies▼
0000Initial CommentsSurveyor note2 building records▼
Findings · record 1 of 2
A recertification survey with complaint #CO37578, #CO37932 and Incident #37862 and #37871 was completed on 10/14/24 to 10/17/24. Nine deficiencies were cited.
Findings · record 2 of 2
An Emergency Preparedness survey was conducted from 10/14/24 to 10/17/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0565Resident/Family Group and ResponseS/S E▼
Findings
Based on record review and resident interviews, the facility failed to promptly address and attempt to resolve resident group complaints and grievances concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to ensure residents felt their concerns with call light timeliness resulting in long waits for staff assistance were addressed and resolved. Findings include:I. Facility policy and procedureThe Resident Council policy, undated, was provided by the nursing home administrator (NHA) on 10/17/24 at 6:04 p.m. The policy read in pertinent part, "The purpose of the resident council is to provide a form for: residents families and resident representatives to input in the operation of the facility; discussion of concerns and suggestions for improvement; consensus building and communication between residents and facility staff; and, disseminating information and gathering feedback from interested residents."A resident council response form will be utilized to track issues and their resolutions. The facility department related to any issues will be responsible for addressing the items of concern."The quality assurance and performance improvement committee (QAPI) will review information and feedback from the resident council as part of their quality review. Issues documented on council response forms may be referred to the committee, if applicable."II. Resident group interview A group interview was conducted on 10/16/24 at 10:32 a.m. with five residents (#2, #8, #15, #16 and #21) the facility assessed and deemed as alert, oriented and interviewable. According to the group, the residents did not feel the facility addressed their concerns of long call light times. Resident #8 said she recently had to wait over an hour and a half before her call light was answered. She said she had to use the restroom and lay down in bed. She said she had horrible back pain but laying down usually helped. She said because she had to wait so long for assistance, it took a day for her to recover from the pain. Resident #2 said some of the nurses did not help answer call lights and relied on the certified nurse aides (CNA) to answer the call lights. She said last month (September 2024) she had to wait over an hour for her call light to be answered. Resident #16 said last Thursday (10/10/24) he had to wait from 4:15 a.m. to 6:00 a.m. for his call light to be answered. The group said the longest waits were usually during the night. III. Resident council minutes The July 2024 resident council minutes documented call lights were addressed as a concern. According to the minutes, call lights were not always timely. The action item on the minutes indicated the resident council was told some of the residents required two staff for transferring, potentially taking the CNAs a little longer to get to the call light. -The July 2024 council minutes did not identify what the facility was going to do to address the concern of inconsistent call light times. The July 2024 resident council grievance form for call light timeliness was requested but was not provided by the facility. The August 2024 and September 2024 resident council minutes did not document the July 2024 concern of inconsistent call light was reviewed with the resident council to determine whether the concern was resolved or not. IV. Call light recordThe electronic call light log between 10/2/24 and 10/15/24 was provided by the operations manager (OM) on 10/16/24 at 6:21 p.m. A five day sample of call light response time, from 10/1/24 to 10/14/24, identified the following:On Wednesday 10/2/24, a total of 200 total call lights were turned on for resident assistance. -40 of the call lights were activated for over 15 minutes before they were answered;-Six of the call lights were answered between 20 and 29 minutes;-14 of the call lights were answered between 30 and 39 minutes;-Two of the call lights were answered between 40 and49 minutes; -Two of the call lights were answered between 50 and 59 minutes; and,-Three call lights were activated for over an hour before the resident's call light was answered. On Thursday 10/3/24, a total of 150 total call lights were turned on for resident assistance. -32 of the call lights were activated for over 15 minutes before they were answered;-Seven of the call lights were answered between 20 and 29 minutes;-Three of the call lights were answered between 30 and 39 minutes;-Seven of the call lights were answered between 40 and 49 minutes; and,-Two of the call lights were answered between 50 and 59 minutes. On Sunday 10/6/24, a total of 162 total call lights were turned on for resident assistance. -14 of the call lights were activated for over 15 minutes before they were answered;-Seven of the call lights were answered between 20 and 29 minutes; -One call light was answered between 30 and 39 minutes; and,-One call light was activated for over an hour (one hour and 33 minutes) before the resident's call light was answered. On Monday 10/7/24, a total of 162 total call lights were turned on for resident assistance. -32 of the call lights were activated for over 15 minutes before they were answered;-12 of the call lights were answered between 20 and 29 minutes;-Two of the call lights were answered between 30 and 39 minutes; and,On Monday 10/14/24, (the first day of the survey period) a total of 200 total call lights were turned on for resident assistance. -11 of the call lights were activated for over 15 minutes before they were answered;-Three of the call lights were answered between 20 and 29 minutes;-One call light was answered between 30 and 39 minutes; -One call light was answered between 40 and 49 minutes; and,-Two call lights were activated for over an hour before the resident's call light was answered. V. Staff interviewsThe activity director (AD) was interviewed on 10/17/24 at 5:00 p.m. The AD said during resident council, the prior resident council concerns were reviewed each month to determine if the concern was resolved or still an ongoing concern. She said the status of the concern would be documented in the minutes. The AD said if the resident council had a new concern or an unresolved concern that was ongoing, she would add the concern to a grievance form. She said the grievance would be submitted to the appropriate department to address the council. The completed grievances would be turned in to the social service director (SSD). The AD said she was not in her position in July 2024 when the resident council brought up the concern of inconsistent call light timeliness. The AD said she would not have known of the call light concern in July 2024 to review in the August 2024 resident council because she was new to her position and was not aware of the July 2024 call light concern. She said she did not review the July 2024 resident council concerns prior to the August 2024 council meeting. The social service director (SSD) said was responsible for filing all grievances from residents and resident council. The SSD said she had not received a call light grievance from the July 2024 resident council meeting. The operations manager (OM) and the NHA was interviewed on 10/17/24 6:32 p.m. The OM said resident feedback was how the facility determined if resident council concerns were appropriately addressed and resolved. He said the concern would be brought up the following to determine if the concern was resolved. He said if the resident council felt the concern remained unresolved, a new grievance would be submitted and addressed for resolution until the resident said they were satisfied. The NHA said call light timeliness was reviewed in QAPI on 10/17/24 (during the survey). The NHA said interdisciplinary team (IDT) reviewed the electronic call light logs and determined more the facility needed to do call light spot audits.
Plan of correction · submitted by the facility
In-service education was provided to all staff on the importance of timely call light responses. This education was completed on 11/01/24. All residents currently residing in the facility will be surveyed via paper document by the Social Services Director to assess satisfaction with call light response times and be educated on the grievance process by 11/11/24. The Social Services Director was educated on 11/01/24, about the importance of ensuring Resident Council concerns are placed as grievances, tracked in the Grievance Log via Excel spreadsheet, and provided to responsible party for follow up in a timely manner. The Social Services Director was educated on 11/01/24, about the appropriate timeframe in which grievances are to be followed up with and completed per facility policy. The Social Services Director will create a resident council complaint form via Excel spreadsheet which will be utilized to track issues and their resolutions brought up during Resident Council. This form will be reviewed during the following resident council meeting to ensure previous resident council group concerns were addressed and met. The Administrator/designee will be reviewing the call light log of 5 random residents on day shift and 5 residents on night shift for long call light times. This 5-day, 5-night, audit will be conducted weekly x 30 days daily. 2-day, 2-night, audit will be completed weekly x 30 days. 5 random residents, day or night, weekly, for 30 days. Tracking for call light audits will be done via Excel spreadsheet. On 10/21/24, the Nursing Home Administrator assigned the Department Heads morning Angel Rounds 5x times weekly, which consists of department heads ensuring care is being met, call lights being answered timely, among other things. These are reviewed at the Daily Stand-up meetings and any concerns will go through the concern process for the Social Services to ensure that there is timely follow-up. The Nursing Home Administrator/designee will track and identify issues with the call light audit and follow-up and report this to the Quality Assurance Performance Improvement committee monthly x 90 days or until compliance is achieved. The Director of Nursing/designee will track any staffing issues related to long call light response times and report issues and trends identified to the Quality Assurance Performance Improvement committee monthly x 90 days or until compliance is achieved. The Director of Nursing/designee will track any staffing issues related to long call light response times and report issues and trends identified to the Quality Assurance Performance Improvement committee monthly x 90 days or until compliance is achieved.
0658Services Provided Meet Professional StandardsS/S D▼
Findings
Based on observation and interviews, the facility failed to ensure one (#12) of one of 26 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #12's blood pressure was measured appropriately in accordance with medical standards of practice. Findings include:I. Professional reference"How to measure your blood pressure at home" fact sheet, dated 2020, was retrieved on 10/21/24 from the American Heart Association medical archives at https://www.heart.org/-/media/Files/Health-Topics/High-Blood-Pressure/measuringbpathome.pdf It documented that the blood pressure cuff should be positioned on the bare arm above the elbow in the middle of the arm. II. Facility policy and procedureThe Blood Pressure, Measuring policy, revised September 2010, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. It documented in pertinent part,"Expose the resident's arm by rolling the sleeve up about five inches above the elbow". II. ObservationOn 10/17/24 at 8:42 a.m. registered nurse (RN) #2 was taking Resident #12's blood pressure. Resident #12 was wearing a pink fleece sweater and offered to roll up her sleeve for the blood pressure measurement. RN #2 declined Resident #12's offer and said that she could take a blood pressure over the clothing items because she had good ears. RN #2 then placed the blood pressure cuff on Resident #12's upper arm over the pink fleece sweater to obtain the blood pressure measurement. RN #2 then documented the blood pressure measurement in the electronic medical record (EMR). III. Staff interviewsRN #2 was interviewed on 10/17/24 at 8:51 a.m. RN #2 said that it was normal and acceptable to obtain a resident's blood pressure over clothing. RN #2 said obtaining a blood pressure in this manner would not affect the accuracy of the blood pressure measurement. The director of nursing (DON) was interviewed on 10/17/24 at 4:08 p.m. The DON said that a blood pressure device could be placed over resident clothing to obtain an accurate blood pressure if the clothing was thin. The DON said she did not know if Resident #12's pink fleece sweater would be thick enough to affect the blood pressure measurement. The DON reviewed the American Medical Association and American Heart Association recommendations for obtaining an accurate blood pressure reading (see professional reference above). The DON said she did not know the American Heart Association recommendations included placing the blood pressure measurement device on the bare arm for accurate measurement.
Plan of correction · submitted by the facility
Resident # 12 had no adverse effects related to the deficient practice and remains at baseline. All residents had the potential to be affected by the alleged deficient practice. All nursing staff will be educated by Director Nursing/designee or how to properly take blood pressure while maintaining professional standards of care and ensuring blood pressure reading accuracy by 11/6/24. The Director of Nursing/designee will complete random weekly audit of nursing staff 3 x a week for 30 days to ensure proper professional standards are being maintained and blood pressure reading accuracy. The Director of Nursing/designee will complete weekly audits 2 x week of nursing staff x 30 days to ensure proper professional standards are being maintained and blood pressure reading accuracy. The Director of Nursing/designee will complete weekly audits of random nursing staff x 30 days to ensure proper professional standards are being maintained and blood pressure reading accuracy. Monitoring will be documented and tracked via paper documentation sheet. The Director of Nursing/designee will complete reports including any issues identified regarding Blood pressure audits to Quality Assurance Performance Improvement committee x 90 days or until compliance is achieved.
0679Activities Meet Interest/Needs Each ResidentS/S D▼
Findings
Based on observations, record review and interviews, the facility failed to ensure one (#15) of three residents reviewed for activities out of 26 sample residents received individualized activities in accordance with standards of care. Specifically, the facility failed to offer Resident #15 activities in Spanish, which was his preferred language. Findings include:I. Resident #15A. Resident statusResident #15, age greater than 65, was admitted on 6/22/19 and readmitted 5/19/24. According to the October 2024 computerized physician orders (CPO), diagnoses included kidney failure, bipolar disorder and type 2 diabetes. According to the 7/17/24 minimum data set (MDS) assessment, Resident #15 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent in completing all activities of daily living. According to the 1/15/24 MDS assessment, it was very important for Resident #15 to have books, magazines and newspapers to read., listen to music he liked., do his favorite activities, go outside and get fresh air when the weather was good and participate in religious services. B. Resident interview and observationResident #15 was interviewed, in Spanish, on 10/14/24 at 3:18 p.m. Resident #15 said he was raised speaking Spanish only and his preferred language was Spanish. Resident #15 said he understood some phrases and words in English, but he was not fluent in English. Resident #15 said he had not been provided with activities in the Spanish language. Resident #15 said he was given word finding books but they were all in English. Resident #15 presented four different word finding books from his bedside table that were written in the English language. Resident #15 said he enjoyed speaking Spanish with the housekeeping staff when he could but they were often too busy to talk to him. Resident #15 said he had no memory of any activity being provided to him in the Spanish language. Resident #15 said he often felt forgotten because he was the only resident who spoke Spanish primarily at the facility. C. Additional observationThe posted facility activity board for the month of October was observed on 10/16/24 at 11:04 a.m. The activity board did not include any activities in the Spanish language for the month of October 2024. D. Record reviewResident #15's activity plan of care, initiated on 7/5/21 and revised 10/24/23 revealed a goal for Resident #15 to participate in activities three to five times per week. It documented Resident #15's in-room interests were television and crossword puzzles. Other activity interests included bingo, movies, church, yahtzee and memory card games. The activity plan of care documented Resident #15 spoke the Spanish and English language, but preferred Spanish. Resident #15's activity participation record was reviewed for 30 days, between 9/16/24 and 10/16/24. The facility had initiated activity participation records including spiritual activities, outings, sensory activities, social activities, one on one visits, visits from friends and family, cognitive activities and creative activities. -The activity participation record failed to reveal any resident-centered Spanish activities were provided to Resident #15 between 9/16/24 and 10/16/24. II. Staff InterviewsCertified nurse aide (CNA) #1 was interviewed on 10/15/24 at 10:11 a.m. CNA #1 said Resident #15 spoke Spanish and English. CNA #1 said Resident #15 did not need language services or activities in Spanish because he spoke English. Registered nurse (RN) #1 was interviewed on 10/16/24 at 8:41 a.m. RN #1 said there was no communication barrier between Resident #15 and staff because Resident #15 spoke English fluently.-However, despite CNA #1 and RN #1 indicating Resident #15 spoke English fluently and therefore did not need language services and activities in Spanish, the resident expressed that he preferred to receive activities in his preferred language of Spanish (see resident interview above). The activity director (AD) was interviewed on 10/17/24 at 1:14 p.m. The AD said her role was to engage the residents in activities that gave them purpose and meaning and kept them from being bored. She said she would ask the residents what they enjoyed doing and add their interests onto the activity calendar. She said she tried to find activities that were similar to the residents' past leisure pursuits. The AD said the activity program did not have activities specific for Spanish-speaking residents. She said once a year the facility celebrated Spanish heritage month. The AD said Resident #15 could speak, read and write in English. She said an activity for Spanish-speaking residents could have been created, however, she said nobody had expressed to her that it was a need. The AD said she had access to Resident #15's care plan but she was not aware that he would want activities that were Spanish specific. She said she did not ask him if he wanted activities and/or reading materials in Spanish. She said he attended bingo, resident council meetings and Catholic church services. The AD said the activities Resident #15 attended were in English and he participated without concern. The director of nursing (DON) was interviewed on 10/17/24 at 10:27 a.m. The DON said there was no documentation that the facility had provided Resident #15 with activities in the Spanish language. The DON said she thought Resident #15 spoke fluent English. The DON said she was not aware Resident #15 wanted activities provided to him in the Spanish language. The DON said the facility had a language interpreter line available to staff if they needed to reach an interpreter for resident communication needs.
Plan of correction · submitted by the facility
1. Resident #15 was interviewed to identify his activities of preference and has been set up with some activities in Spanish that he feels he would enjoy that will support his physical, psychosocial and mental health. 2. Residents currently residing in the facility are being interviewed by activities staff to ensure that their activities programs are meeting their physical, psychosocial and mental health needs as they choose to participate with a completion date of 11/11/24. Care Plans will be updated to reflect any changes noted during resident interviews. 3. The Administrator provided education on 11/7/24 on the expectation of care planning activity preferences which will be updated quarterly and PRN.4. The Administrator/Designee will complete an audit of 5 random residents 3 x weekly x 30 days, 3 randoms residents weekly x 30 days and 2 random residents weekly x 30 days for supporting documentation that activities preferences are being met. Audit will be documented and tracked via an Excel spreadsheet. 5. The Administrator will track and trend issues from the above audits and bring the results to the QAPI committee monthly x 90 days or until compliance is achieved.
0689Free of Accident Hazards/Supervision/DevicesS/S E▼
Findings
Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for four of ten resident rooms and one (#6) of two residents reviewed for accidents out of 26 sample residents, received adequate supervision to decrease and/or prevent risk for accident hazards. Specifically the facility failed to: -Ensure tap water in the facility was kept within a safe temperature range; -Initiate a timely fall care plan and interventions to prevent falls for Resident #6; and, -Ensure Resident #6's neurological assessments were completed after the resident sustained an unwitnessed fall in her room on 8/21/24. Findings include:I. Failure to ensure safe water temperaturesA. Professional referenceAccording to the Consumer Product Safety Commission (CPSC) Safety Alert, Avoiding Tap Water Scalds, retrieved on 10/23/24 from https://www.cpsc.gov/s3fs-public/5098-Tap-Water-Scalds.pdf, "The majority of injuries and deaths involving tap water scalds are to the elderly and children under the age of five. The U.S. Consumer Product Safety Commission (CPSC) urges all users to lower their water heaters to 120 degrees Fahrenheit (F)."B. Facility policy and procedureThe Water Temperatures, Safety Of policy, revised December 2009, was provided by the nursing home administrator (NHA) on 10/17/24 at 4:17 p.m. The policy read in pertinent part, "Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 112 degrees Fahrenheit (F) or the maximum allowable temperature per state regulation. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic water temperature checks and record the water temperature in a safety log."C. Observations and resident interviewsThe tap hot water temperatures from resident rooms were obtained on 10/17/24 between 10:05 a.m. and 10:23 a.m. The hot water in each resident room ran for approximately one minute prior to taking the water temperature. The hot water temperatures were as follows: -At 10:17 a.m. the water temperature from the sink in room #104 was 131 degrees F.The temperature gauges for the two facility hot water heaters were reviewed with the maintenance service director (MSD) at 3:42 p.m. The first hot water heater was located in the 100 hall. The hot water heater serviced the 100 hall (six) resident rooms. The temperature gauge of the hot water heater read 138 degrees F. The second hot water heater was located in the 400 hall and serviced the remainder of the facility rooms. The temperature gauge of the hot water heater read 140 degrees F. The tap hot water temperatures from resident room sinks and the one facility shower room were obtained on 10/17/24 between 3:50 p.m. and 4:00 p.m. The hot water temperature were as follows: -The shower room temperature registered 110 degrees F after one minute.-Room #104 registered a hot water temperature of 130.8 degrees F after one minute. One resident who resided in room #104 said the water was hot and she was able to adjust the temperature with cold water, however, she said the staff usually helped her with everything she needed to do at the sink. The second resident who resided in room #104 said she had not had any problems with the hot water temperature from the sink. She said the water got warm but she was able to adjust the water temperature as needed. -Room #105 registered a hot water temperature of 131 degrees F after one minute. The resident who resided in room #105 was bed bound. The resident said she did not use the sink in her room and the staff helped her with all of her activities of daily living (ADL) care. -Room #101 registered a hot water temperature of 131.5 degrees F after one minute. The resident who resided in room #101 said he did not use the sink by himself. He said the staff would help him at the sink. D. Record reviewThe resident room water temperature log was provided by the NHA on 10/17/24 at 4:17 p.m. The water temperature log documented water temperatures were taken weekly in random resident rooms, one to two rooms on each hall. Review of the resident room water temperatures from 9/19/24 to 10/14/24 revealed hot water temperatures ranged from 104 degrees F to 117 degrees F, excluding 10/2/24 when the hot water temperatures were documented as 75 degrees F (see interview below). E. Staff interviewsThe maintenance services director (MSD) was interviewed on 10/17/24 at 3:42 p.m. The MSD said hot water temperatures in resident rooms and the shower room should range between 100 degrees F and 112 degrees F.The MSD said he had limited training on the hot water heaters. He said if he had questions with the hot water heaters, he would contact the regional plant operations director. The MSD said he would not usually look at the temperature gauge of the water heaters. He said he mainly just made sure the water pressure was not too high or too low. He said he used resident room temperatures to determine the facility's hot water temperature range. The MSD was interviewed a second time during the above observations on 10/17/24 between 3:50 p.m. and 4:00 p.m. He said when he checked the hot water temperatures in the residents' rooms during his weekly audit, the temperatures were within an appropriate temperature range. He said he did not know what had changed since his last audit on 10/14/24. The MSD said he did not adjust anything with hot water temperatures and no one had expressed any concerns to him regarding the water temperatures being too hot. The MSD said he would immediately turn the hot water temperature down on the facility's hot water heaters based on 10/17/24 observations. The NHA was interviewed on 10/17/24 at 4:20 p.m. The NHA said the regional plant operations director was contacted and felt the mixing valve on the hot water heaters had gone out. The NHA said there was only one incident that was reported to him regarding the hot water heaters being too cold, not too hot. The NHA was interviewed a second time on 10/17/24 at 4:51 p.m. He said the MSD had temporarily shut the water off to the 100 hall. He said the MSD was in the process of draining the water and then would refill the hot water heater. The NHA said the hot water heater temperature setting would be lowered. He said a vendor was contacted but could not fix the mixing valve until 10/23/24. The NHA said the MSD would conduct frequent checks of the hot water until all repairs could be made. The NHA said the residents on the 100 hall were either bed bound, dependent on staff to assist them at the sink, or physically and cognitively able to adjust the water temperature to a safe and comfortable temperature. The operation manager (OM) was interviewed on 10/17/24 at 4:53 p.m. The OM said the facility had had some problems with the hot water heaters. He said one of the hot waters was not working but the other two were operational. He said the pilot light to one of the heaters was going out about once a month. He said a vendor was not contacted. He said the regional plant operations manager looked at the hot water heaters and did not see a concern. The OM said when the pilot light went out, the facility just relit it. He said the focus of the hot water heaters had been making sure the water was not cold, not that it was too hot. The OM and the DON were interviewed together on 10/17/24 at 6:32 p.m. The OM said he had not had any reports of hot water concerns. The DON said hot water temperatures over the recommended value increased the risk of burns to older adults. II. Failure to initiate a timely fall care plan and interventions to prevent falls and complete neurological assessments after a fall for Resident #6A. Professional referenceAccording to Potter, P.A., Perry, A.G., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 1780, retrieved on 10/21/24, "In the event of a fall, perform a post-fall assessment to identify possible causes. Monitor patients closely for 48 hours after a fall."B. Facility policyThe Fall Management System policy, dated June 2022, was obtained from the director of nursing (DON) on 10/17/24 at 10:57 a.m. It documented in pertinent part,A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force, such as a resident pushing another resident, whether the event was witnessed or unwitnessed."The presence or absence of a resultant injury is not a factor in the definition of a fall. A fall without an injury is still a fall."The distance to the next lower surface is not a factor in determining if a fall occurred. If a resident rolled off a bed or mattress that was close to the floor, it is still a fall."When a fall occurs, the resident is assessed for injury by the nurse."In the event a resident has a fall, and it has been determined they hit their head, or it cannot be determined if they hit their head (the fall was unwitnessed or the patient cannot verbalize if they hit their head), the nurse initiates the following actions: neurological checks are completed and documented per instructions."C. Resident status Resident #6, age greater than 65, was admitted on 12/23/13. According to the October 2024 computerized physician orders (CPO), diagnoses included stroke, chronic obstructive pulmonary disease (COPD), and chronic kidney disease stage three. The 7/6/24 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. She was independent while eating, required substantial assistance with oral hygiene and was dependent on nursing staff for all other cares. D. Record reviewThe fall care plan, initiated 8/26/24, documented that Resident #6 was a high fall risk. Interventions included anticipating resident needs, ensuring the resident's call light was within reach, educating the resident on what to do if a fall occurred, encouraging a helmet, which the resident frequently refused, encouraging the resident to participate in activities that promoted exercise, ensuring the resident was wearing appropriate footwear, placing a fall mat beside the resident's bed, providing a transfer pole beside the resident's bed and following the facility's fall protocol. Fall risk evaluation dated 2/5/24 documented the resident was at a high risk for falls. An interdisciplinary team (IDT) post fall review dated 2/5/24 documented Resident #6 experienced an unwitnessed fall on 2/5/24 at 1:24 a.m. -However, the facility failed to initiate a fall prevention plan of care and fall interventions until after the resident fell again on 8/21/24 (see care plan above). A fall risk evaluation dated 7/2/24 documented the resident was at a high risk for falls. A nurse progress note dated 8/21/24 documented that, at 4:10 p.m., Resident #6 was found on the floor and had reported she hit her head while trying to self-transfer. The progress note documented the DON and two certified nurse aides (CNA) asked Resident #6 if she hit her head and Resident #6 responded yes. The note documented the resident was able to express her concerns without issue. -Review of Resident #6's electronic medical record (EMR) did not reveal documentation which indicated neurological assessments were completed for the resident following her unwitnessed fall on 8/21/24. E. Staff interviews CNA #1 was interviewed on 10/15/24 at 3:41 p.m. CNA #1 said if a resident had an unwitnessed fall, she would get the nurse immediately to assess the resident while she obtained vital signs on the resident. CNA #1 said it was normal for nurses to perform neurological assessments frequently for 48 hours after a fall to ensure nothing happened to the resident. Registered nurse (RN) #1 was interviewed on 10/16/24 at 8:58 a.m. RN #1 said if a residenthad an unwitnessed fall, the nurse would complete a neurological assessment and obtain vital signs. RN #1 said if a head injury was suspected or confirmed, neurological assessments would be performed on a regimented schedule for 48 hours. The DON was interviewed on 10/17/24 at 10:41 a.m. The DON said she was the nurse that responded when Resident #6 fell on 8/21/24. The DON said ongoing neurological assessments were not completed for Resident #6 as part of the post-fall assessment. The DON said the ongoing neurological assessments should have been completed. The DON said that the facility had call light logs that were reviewed daily by the administration. The DON said longer call lights could contribute to an increase in the chance for falls. The DON said obtaining sufficient nurse staffing had been a difficulty for the facility. The DON said the facility was issuing more overtime to current nursing staff than before and administration had been covering night shifts on the floor to ensure appropriate nurse staff coverage. Cross-reference F725 for failure to provide sufficient nursing staff. The DON and the nursing home administrator were interviewed again on 10/17/24 at 6:32 p.m. The NHA said he knew call light response times were contributing to falls in the facility. The NHA said if a resident had to wait too long for help, the resident might get impatient and attempt to get up unassisted.
Plan of correction · submitted by the facility
On 10/17/24, the Maintenance Director cut off water to the 100 hall, drained the hot water heater completely, and refilled it. The water heater temperature was then adjusted to a low setting to prevent unsafe temperature levels, ensuring resident safety. Following this adjustment, the Maintenance Director rechecked and logged water temperatures via paper documentation and TELS log, throughout the entire 100 hall, confirming that temperatures were within the safe range per facility policy. On 10/18/24, the facility contacted A1 Heating and Cooling. A vendor technician assessed the water system and identified a malfunctioning mixing valve. The mixing valve replacement was scheduled, and the vendor returned on 11/08/24 to complete the installation. Weekly water temperature checks and logging via paper documentation and TELS logs will continue to ensure temperatures remain within the safe range. The Maintenance Director or designee will review the logs weekly for the next 90 days to identify any temperature fluctuations and ensure consistent compliance with safety standards. The Maintenance Director will report findings from the weekly temperature audits to the Quality Assurance Performance Improvement committee monthly x 90 days to verify sustained compliance. Any noted issues will prompt additional intervention to maintain safe water temperatures facility-wide. Resident # 6 remains at baseline without adverse effects related to falls. Residents currently residing in the facility have the potential to be affected by this alleged deficient practice. Resident #6 is having their call light responded to in a timely manner as long as the staff is not dealing with an urgent situation at that moment that would take priority. In the event of an unwitnessed fall neurological assessments will be completed per facility protocol to ensure no adverse effects occur related to a fall. All staff will receive training on the facility’s Falls policy and procedures, led by the Director of Nursing or designee, by 11/7/24. For any unwitnessed falls, neurological assessments will be conducted according to facility protocol to monitor and prevent potential adverse effects. Interdisciplinary Team will review all falls at the daily clinical meeting along with the completion of neurological assessments to ensure proper interventions are implemented to prevent or reduce falls from occurring. All falls will be tracked weekly and audited to ensure interventions are implemented and updated on the resident’s care plan and neurological assessments are complete for each unwitnessed fall x 90 days to ensure compliance is achieved. Audit documentation will be tracked and logged via paper documentation sheet. The Director of Nursing/designee will track and identify issues with falls and completion of neurological assessments and follow up with a completed report and review this to the Quality Assurance Performance Improvement committee to ensure that compliance is maintained for at least a period of 3 months.
0692Nutrition/Hydration Status MaintenanceS/S D▼
Findings
Based on observations, record review and interviews, the facility failed to ensure one (#6) of three residents reviewed out of 26 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Specifically, the facility failed to:-Accurately obtain and document Resident #6's weights; and, -Weigh Resident #6 per physician's orders. Findings include:I. Facility policy and procedureThe Nutritional Assessment policy, revised October 2017, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. It documented in pertinent part,"As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition."II. Resident #6A. Resident statusResident #6, age greater than 65, was admitted on 12/23/13. According to the October 2024 computerized physician orders (CPO), diagnoses included stroke, chronic obstructive pulmonary disease (COPD) and chronic kidney disease stage three. The 7/6/24 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. She was independent while eating, required substantial assistance with oral hygiene, and was dependent on nursing staff for all other cares. The assessment documented Resident #6 had no rejections of care. The assessment documented the resident was 65 inches (5 foot, 5 inches) tall. The assessment documented the resident weighed 253 pounds (lbs). The assessment documented the resident had not experienced weight loss in the last six months. B. Record reviewThe nutrition care plan, initiated on 8/26/16 and revised 1/11/2020, revealed Resident #6 and Resident #6's family were non-compliant with diabetes management and had received education previously. The care plan documented interventions included avoiding exposure to extreme heat or cold, to check the body for breaks in skin and provide treatment promptly, providing diabetes medications as ordered by the physician, providing a dietary consult for nutritional regimen and ongoing monitoring, discussing meal times and portion sizes, educating Resident #6 regarding the importance of dietary compliance, and educate Resident #6 and family as to the correct protocol for glucose monitoring and insulin injections. Resident #10's weights were documented in the electronic medical record (EMR) as follows:-On 4/28/24, the resident weighed 253.2 lbs;-On 5/6/24, the resident weighed 252.0 lbs;-On 6/2/24, the resident weighed 253.0 lbs;-On 9/18/24, the resident weighed 213.5 lbs;-On 9/27/24, the resident weighed 213.0 lbs; and,-On 10/7/24, the resident weighed 214.5 lbs.-The facility failed to accurately subtract the weight of the wheelchair on 4/28/24, 5/6/24 and 6/2/24 (see facility follow-up below). A review of physician's orders in the EMR revealed a physician's order to obtain Resident #6's weight weekly on Sundays for four weeks, then to obtain Resident #6's weight per facility protocol, ordered on 4/7/24 and discontinued on 10/14/24.-The facility failed to obtain and document Resident #6's monthly weight per physician's order in July 2024 and August 2024 .The 1/4/2020 comprehensive nutritional assessment documented Resident #6's admission weight was 257 lbs and Resident #6's usual body weight was 250 pounds. The 4/12/24 nursing at risk review note, dated 4/12/24, documented the resident was consistently eating less than 25% of all meals. The 6/20/24 nutritional assessment documented there were no significant changes with Resident #6's weight recently. The assessment documented the resident was consistently eating 75% to 100% of all meals.-The facility failed to accurately subtract the weight of the wheelchair on 4/28/24, 5/6/24 and 5/2/24 (see facility follow-up below). The 9/18/24 nursing at risk review note documented Resident #6 weighed 213.5 pounds. The note documented this was a weight gain from July 2024.-However, a review of the resident's EMR did not include documentation indicating the facility weighed the resident in July 2024. Facility weight performance improvement plan (PIP) documentation, dated 9/6/24, was provided by the director of nursing (DON) on 10/16/24 at 3:19 p.m. It documented that the facility identified a need to improve the accuracy of documented weights. It documented that education was provided to bedside nursing staff regarding appropriate equipment usage and documentation. III. Staff interviewsThe registered dietitian (RD) was interviewed on 10/17/24 at 11:46 a.m. The RD said she had been in her role for two months. The RD said that she was present in the building every other week on Wednesdays. The RD said that she created nutritional recommendations by interviewing staff on how the resident is doing, interviewing residents themselves, and by reviewing the electronic health record. The RD said when a resident experienced weight loss the care plan should be updated, the dietitian and family should be notified, and new interventions to reduce or prevent the weight loss should be put into place. The RD said she had an internal spreadsheet that tracked residents for which she had concern for weight loss or weight gain in the facility. The RD said Resident #6 was not identified as having a concern with weight loss. The director of nursing (DON) was interviewed on 10/17/24 at 12:20 p.m. The DON said she expected all residents to be weighed monthly unless there was a physician's order that indicated otherwise. The DON said Resident #6's weight loss was expected and the physician was aware of the weight loss. The DON said Resident #6 was not identified as having weight loss in interdisciplinary (IDT) team meetings. The DON said the facility had implemented a performance improvement plan for obtaining and documenting accurate resident weights in the facility on 9/6/24.-However, the facility provided additional documentation indicated t the weight discrepancy was because nursing staff inaccurately obtained and recorded Resident #6's weight on 4/28/24, 5/6/24, and 6/2/24 (see facility follow-up below). IV. Facility follow-upAdditional documentation was received from the DON on 10/21/24 at 2:09 p.m. (after the survey). The facility documentation documented that Resident #6 had not experienced severe weight loss because the weights were obtained and recorded inaccurately. The facility documentation indicated Resident #6's wheelchair weighed 43.5 lbs and this was not correctly subtracted from weights recorded on 4/28/24, 5/6/24 and 6/2/24. The facility documentation indicated an additional weight was obtained in the month of July 2024.-However, no verification that this was completed was included in the submitted documentation. No verification of Resident #6's wheelchair weight was included in the submitted documentation or in the resident's EMR.
Plan of correction · submitted by the facility
Resident # 6 weights have been corrected based on documentation obtained for weights 4/28/24, 5/6/24, 6/2/24/, July weight has been added and August weight has been added. Resident # 6 has noted a gradual weight loss which is expected due to current medication, Trulicity for management of diabetes and corrected weights in in resident’s chart. Resident # 6 remains at baseline without adverse effects related to the alleged deficient practice. All residents have potential to be affected by the alleged deficient practice. All staff have been educated on the facility Nutrition Policy and Procedure, weekly and monthly weights expectations and documentation of weights. Weights will be obtained as ordered and provided to the Director of Nursing/designee for entry into the resident’s record to avoid weight discrepancies. All wheelchairs have been weighed and recorded on weight sheets for accuracy of wheelchair weights. Director of Nursing/designee will review weights weekly during At Risk Review meeting to ensure no weight loss is noted and ensure appropriate interventions are implemented to avoid weight loss. Director of Nursing/designee will audit weekly weights of 5 random residents x 30 days, audit weekly weights of 3 random residents x 30 days and weekly audits of 2 random residents x 30 days to ensure no weight loss unless desired is noted. Audit documentation will be tracked and logged via paper documentation sheet. Director of Nursing/designee will review and report at trends or issues noted to Quality Assurance Improvement Performance committee x 90 days until compliance is achieved.
0725Sufficient Nursing StaffS/S E▼
Findings
Based on record review and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required in a timely manner. Specifically, the facility failed to answer call lights in a timely manner for residents requesting staff assistance. Findings include:I. Facility policyThe Staffing policy, revised October 2017, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. The policy read in pertinent part,"Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care."Other support services are also staffed to ensure that resident needs are met."II. Resident council meeting minutesThe July 2024 resident council meeting minutes documented call lights were addressed as a concern. According to the meeting minutes, call lights were not always timely. The action item on the meeting minutes, the resident council was informed by the facility that some residents required two staff members for transferring, potentially taking the certified nurse aides (CNA) a little longer to answer the call lights. -The July 2024 resident council meeting minutes did not identify what the facility was going to do to address the residents' concern of untimely call light times. Cross reference F565 for failure to follow up on group grievances. III. Facility assessmentThe facility assessment, dated 10/1/24, was provided by the nursing home administrator (NHA) on 10/14/24 at 10:08 a.m. The facility assessment documented the care needs of 40 residents in the facility. The facility assessment documented that the 100 and 200 halls required one licensed nurse and two CNAs to care for the 18 residents residing on both halls during the day shift. It documented that the night shift on 100 and 200 halls also required one nurse and one CNA. It documented the 300 and 400 halls required one nurse and two CNAs to care for the 22 residents residing on both halls during the day shift. It documented the night shift on the 300 and 400 halls also required one nurse and one CNA.The facility assessment documented that 18 residents required moderate assistance with personal hygiene and 14 residents required maximal assistance or were dependent on nursing staff for personal hygiene care. The assessment documented 21 residents required moderate assistance with bathing and 14 residents required maximal assistance or were dependent on nursing staff for bathing assistance. The assessment documented six residents required moderate assistance with their toileting program and 17 residents required maximal assistance or were dependent on staff for assistance with their toileting program. IV. Nursing staff time card and pay stub record reviewNursing staff time cards and pay stubs were reviewed on 25 working days between 4/6/24 and 9/1/24. The review revealed the facility had only one bedside nurse working during the day shift on 4/6/24, 4/7/24, 4/21/24, 4/23/24, 5/20/24, 5/21/24, 5/27/24, 6/1/24, 6/9/24, 6/11/24, 6/29/24, 6/30/24, 8/30/24, 8/31/24 and 9/1/24. -However, the facility assessment documented the facility required two bedside nurses working during the day shift.-Additionally, the director of nursing (DON) said the facility required two bedside nurses working during the day shift (see DON interview below). V. Resident interviewsResident #8 was interviewed on 10/14/24 at 11:14 a.m. Resident #8 said she often had to wait 30 minutes to over an hour for her call light to be answered. Resident #8 said she and her roommate often requested help at the same time to get a more timely response from staff. Resident #8 said she waited most frequently in the afternoon for assistance. Resident #8 said she and many other residents had complained about slow call light response times to administration in the past but nothing had been done to improve call light response times. Resident #8 said she felt she was forgotten and unimportant tonursing administration. Resident #8 said the bedside nursing staff were working as hard as they could but they could not keep up with the residents' needs during the day. Cross-reference F565 for failure to follow up on group grievances. Resident #5 was interviewed on 10/14/24 at 2:12 p.m. Resident #5 said she often had to wait more than 30 minutes for staff to respond to her call light. Resident #5 said the nursing administration knew call light response times were slow but they were not doing anything to improve staffing in the facility. Resident #5 said she stopped using her call light as often if she felt she could do something independently. Resident #5 said she felt conflicted asking for help knowing other residents would not be cared for when she was offered assistance instead. Resident #28 was interviewed on 10/15/24 at 8:55 a.m. Resident #28 said he often waited more than 30 minutes for assistance from staff. Resident #28 said he required maximum assistance with most of his cares throughout the day. Resident #28 said he sometimes called for assistance before he actually needed it because he knew he would have to wait for a long time for the staff to come assist him. Resident #28 said he felt frustrated that nursing staff was always short staffed. Resident #23 was interviewed on 10/15/24 at 9:22 a.m. Resident #23 said she had sometimes waited more than 30 minutes for assistance from staff on many occasions in the past month. Resident #23 said she thought the facility was purposely staffed with as few nurses and CNAs as possible. Resident #23 said she felt less important than a nickel when it took staff so long to assist her. Resident #6 was interviewed on 10/16/24 at 9:09 a.m. Resident #6 said she often waited more than 30 minutes for assistance from staff. Resident #6 said she did not like waiting more than 30 minutes for assistance. Resident #6 said waiting long periods of time for staff assistance happened more frequently at night for her. VI. Call light records from 10/2/24 to 10/16/24Call light records were provided by the nursing home administrator (NHA on 10/16/24 at 6:11 p.m. A 14 day sample of call light response times, from 10/2/24 to 10/16/24, identified the following:On 10/2/24, a total of 200 resident call lights were turned on for resident assistance.. Bedside nursing staff required more than 15 minutes to respond to 40 of those call lights, representing 20% of all call lights turned on by residents for the day. On 10/3/24, a total of 150 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 32 of those call lights, representing 21.3% of all call lights turned on by residents for the day. On 10/4/24, a total of 126 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 23 of those call lights, representing 18.2% of all call lights turned on by residents for the day. On 10/5/24, a total of 141 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 23 of those call lights, representing 16.3% of all call lights turned on by residents for the day. On 10/6/24, a total of 162 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 14 of those call lights, representing 8.6% of all call lights turned on by residents for the day. On 10/7/24, a total of 163 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 32 of those call lights, representing 19.7% of all call lights turned on by residents for the day. On 10/8/24, a total of 144 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 19 of those call lights, representing 13.2% of all call lights turned on by residents for the day. On 10/9/24, a total of 167 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 16 of those call lights, representing 9.6% of all call lights turned on by residents for the day. On 10/10/24, a total of 162 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 29 of those call lights, representing 17.9% of all call lights turned on by residents for the day. On 10/11/24, a total of 169 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 35 of those call lights, representing 20.7% of all call lights turned on by residents for the day. On 10/12/24, a total of 122 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 21 of those call lights, representing 17.2% of all call lights turned on by residents for the day. On 10/13/24, a total of 144 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 19 of those call lights, representing 13.2% of all call lights turned on by residents for the day. On 10/14/24, a total of 147 resident call lights were turned on for resident assistance. Bedside nursing staff required more than 15 minutes to respond to 11 of those call lights, representing 7.5% of all call lights turned on by residents for the day. On 10/15/24, a total of 207 resident call lights were turned on for resident assistance. Bedside nursing staff responded to all call lights in 15 minutes or less on this day. On 10/16/24, a total of 130 resident call lights were turned on for resident assistance between midnight and 5:36 p.m. Bedside nursing staff required more than 15 minutes to respond to three of those call lights, representing 2.3% of all call lights turned on by residents during that time period. VII. Staff interviewsThe DON was interviewed on 10/17/24 at 10:27 a.m. The DON said it was normal to have two nurses working during the day and one nurse working at night. The DON said all of the nurses and CNAs in the facility were agency staff except for a few that were full time at the facility. The DON said she had experienced many difficulties in hiring staff at the facility. The DON said the cost of living where the facility was located presented a significant challenge for hiring staff. The DON said finding nursing coverage on all days and nights had been difficult for the facility. She said several administration staff, including herself, had worked night shift recently to ensure the facility had nursing coverage. The DON said the facility had seen an increase in the use of overtime hours for bedside staff recently. The DON said she had reviewed the resident call light logs provided to the survey team. She said call lights had been long recently and this was something the facility had been working on for several months. The DON said there was not an active and identified performance improvement plan regarding call light response time. The DON reviewed the resident call light log data for 10/15/24 and said she did not know why the facility recorded zero call lights over 15 minutes in length on that day. The DON said it was possible that additional administrative personnel, present for the survey, could have had a positive impact on call light response times seen during the recertification survey. The NHA was interviewed on 10/17/24 at 6:32 p.m. The NHA said he knew call light response times were contributing to falls in the facility. The NHA said if a resident had to wait too long for help, they might get impatient and attempt to get up unassisted. Cross reference F689 for failure to prevent accidents/hazards.
Plan of correction · submitted by the facility
1. Resident #8 was interviewed on 11/11/24 for call light satisfaction and described satisfaction as neutral. Resident #8 is having their call light responded to in a timely manner as long as the staff is not dealing with an urgent situation at that moment that would take priority. Resident #5 was interviewed on 11/11/24 for call light satisfaction and described satisfaction as satisfied. Resident #5 is having their call light responded to in a timely manner as long as the staff is not dealing with an urgent situation at that moment that would take priority. Resident #28 was interviewed on 11/11/24 for call light satisfaction and described satisfaction as satisfied. Resident #28 is having their call light responded to in a timely manner as long as the staff is not dealing with an urgent situation at that moment that would take priority. Resident #23 discharged from the facility on 10/24/24. Resident #6 was interviewed on 11/11/24 for call light satisfaction and described satisfaction as dissatisfied. Resident #6’s concern was placed on a grievance and went through facility grievance process. Resident signed off on grievance on 11/12/24 and accepted our grievance course of action. 2. Residents currently residing in the facility have the potential to be affected by this alleged deficient practice. 3. All residents currently residing in the facility will be surveyed by the Social Services Director to assess satisfaction with call light response times and be educated on the grievance process by 11/11/24.4. In-service education was provided to all staff on the importance of timely call light responses and facility call light policy. This education was completed on 11/01/24.5. The Administrator/designee will be reviewing the call light log of 5 random residents on day shift and 5 residents on night shift for long call light times. This 5-day, 5-night, audit will be conducted weekly x 30 days daily. 2-day, 2-night, audit will be completed weekly x 30 days. 5 random residents, day or night, weekly, for 30 days. Tracking for call light audits will be done via Excel spreadsheet. 6. The daily Schedule is reviewed each morning at the daily clinical meeting by the Director of Nursing for the next three days in advance to identify any open shifts. The facility is pursuing aggressive recruiting efforts to hire and maintain staff. 7. On 10/21/24, the Nursing Home Administrator assigned the Department Heads daily morning Angel Rounds, which consists of department heads ensuring care is being met, call lights being answered timely, among other things. These are reviewed at the Daily Stand-up meetings and any concerns will go through the concern process for the Social Services to ensure that there is timely follow-up. 8. The Administrator/designee will track and identify issues with the call light audit and follow-up and report this to the Quality Assurance Performance Improvement committee monthly x 90 days or until compliance is achieved. 9. The Director of Nursing/designee will track any staffing issues related to long call light response times and report issues and trends identified to the Quality Assurance Performance Improvement committee monthly x 90 days or until compliance is achieved. 10. The Director of Nursing/designee will track any staffing issues related to long call light response times and report issues and trends identified to the Quality Assurance Performance Improvement committee monthly x 90 days or until compliance is achieved.
0804Nutritive Value/Appear, Palatable/Prefer TempS/S E▼
Findings
Based on resident interviews, staff interviews, and observations, the facility failed to ensure residents were provided with food cooked and served in a manner that conserved nutritive value, flavor, appearance, texture and at an appetizing temperature. Specifically, the facility failed to consistently serve foods at a palatable texture. Findings include:I. Facility policy and procedureThe Critical Temperatures for Safe Food Handling policy, undated, was provided by the dietary manager (DM) on 10/17/24 at 5:44 p.m. The policy read in pertinent part, "Temperature should be taken periodically to assure hot food stays above 135 degrees Fahrenheit (F) and cold food stays below 41 degrees F during the serving process. Maintain a cold enough holding temperature to assure foods are maintained at or below 41 degrees F until they leave the service area."The Food and Nutrition Services Staff policy, undated, was provided by the DM on 10/17/24 at 6:21 p.m. The policy read in part, "Food will be palatable, attractive and served in a timely manner at proper temperatures." II. Resident interviewsResident #28 was interviewed on 10/14/24 at 3:50 p.m. He said the food was not palatable. He said he ate in the dining room and the food was often served cold when it should be warm. He said he would eat a lot of sandwiches because he did not like being served cold food. Resident #39 was interviewed on 10/14/24 at 3:58 p.m. She said she ate in her room and food was often delivered to her cold. Resident #15 was interviewed on 10/14/24 at 5:17 p.m. He said he always ate his food in his room and was served cold food often. He said he was served cold food for breakfast on 10/14/24 and cold food for lunch on 10/13/24. III. Resident group interviewA group interview was conducted on 10/16/24 at 10:32 a.m. with five alert and oriented residents (#2, #8, #15, #16 and #21) through facility and assessment. Four (#2, #8, #15, and #21) of the residents in the group interview said the food was served cooler than their preference. Resident #21 said he felt the dinner meals tended to be cold when he received the meal tray in his room. Resident #2 said she frequently saw the hot box mobile food cart door left open when staff served room trays. She said the food was served covered in plastic wrap instead of hard cover lids to maintain the heat. IV. ObservationsDuring a continuous observation of the dinner meal service on 10/16/24, beginning at 3:55 p.m and ending at 5:22 p.m., the following was observed: At approximately 4:35 p.m. cook (CK) #1 placed a container of garden salad on top of a container filled with ice and took the temperature of the salad. The garden salad registered a temperature of 41 degrees F. CK #1 said 41 degrees was the highest temperature the salad could be held at. At 4:43 p.m. meal service began and staff proceeded to cover room tray plates with plastic wrap and place them into the hot box mobile food cart. At 5:01 p.m. the hot box cart left the dining room for the room tray meal service. Between 5:02 p.m. and 5:08 p.m. the hot box cart door was left open while staff served room trays. The hot box cart was not plugged into an electrical outlet to maintain the heat of the meals trays left in the cart. A test tray for a regular diet was evaluated by two surveyors immediately after the last resident had been served their room tray for dinner on 10/16/22 at 5:23 p.m. The test tray consisted of vegetable pot pie and a garden salad with cheese, tomatoes and lettuce. The salad was served on the same plate as the pot pie. -The lettuce and tomatoes were slightly warm in touch and taste. The salad was 85.2 degrees F. -The vegetable pot pie was lukewarm. The vegetable pot pie was 107 degrees F. V. Staff interviewsCK #1 was interviewed on 10/16/24 at 5:35 p.m. CK #1 said the garden salad was kept on ice until it was served to make sure it was served at a safe and palatable temperature. He said the salad had cheese on it and he would not want the salad to have a chance to grow bacteria if it was not kept at or below 41 degrees F. CK #1 said he would not want to eat a warm salad. He said the garden salad should have been kept cold. He said he hoped staff would not set the hot box food cart on the highest setting or plug in the hot box so the salad temperature would not rise too high while in the hot box with warm food. The DM was interviewed on 10/17/24 at 5:21 p.m. The DM said food could not be held in the danger zone to prevent bacteria growth. She said the temperature danger zone was a range of over 41 degrees F and under 135 degrees F. The DM said she wanted food to be held at between 145 degrees F and 165 degrees to make sure food was served warm. The 10/16/24 observations were reviewed with the DM. She said placing the garden salad in the hot box for room service would raise the temperature of the salad. She said the staff should have placed the salad in a container on ice during room service to help maintain the temperature for a cold salad. She said the cheese on the garden salad was dairy which could quickly become compromised with an increased temperature. The DM said hot foods such as the vegetable pot pie should be served at a warm palatable table. She said the hot box should be plugged in during room tray delivery and the door should be closed after each retrieval of a room tray and kept shut to maintain the temperature of the hot food items.
Plan of correction · submitted by the facility
Resident #28 was interviewed on 11/11/24 regarding the flavor, appearance, texture, and appetizing temperature of the food served at the facility. The results of the residents’ interview indicated the need to file a grievance regarding the resident’s feedback. Grievance was filed on 11/11/24, and completed on 11/12/24. Resident #39 was interviewed on 11/11/24 regarding the flavor, appearance, texture, and appetizing temperature of the food served at the facility. The results of the residents’ interview indicated the resident was satisfied in the areas of concern. Resident #15 was interviewed on 11/11/24 regarding the flavor, appearance, texture, and appetizing temperature of the food served at the facility. The results of the residents’ interview indicated the resident was satisfied in the areas of concern. Resident #2 was interviewed on 11/11/24 regarding the flavor, appearance, texture, and appetizing temperature of the food served at the facility. The results of the residents’ interview indicated the resident was satisfied in the areas of concern. Resident #21 was interviewed on 11/11/24 regarding the flavor, appearance, texture, and appetizing temperature of the food served at the facility. The results of the residents’ interview indicated the resident was satisfied in the areas of concern. All residents residing in the facility have the potential to be affected by the alleged deficiency. All dietary staff have were re-educated by the Dietary Manager on 10/24/24 regarding the FDA Food Code Section 3-501.16, focusing on maintaining safe and appetizing food temperatures. The training included procedures for ensuring cold items are kept separate from hot items and served at appropriate temperatures. A test tray will be prepared daily during lunch for six weeks to monitor food temperatures and palatability. Each tray will be tasted by a randomized staff member who will complete a test tray sheet. Test tray sheets will be recorded and tracked via paper documentation. Resident feedback will also be collected via paper documentation during resident council meetings to ensure satisfaction with food temperature and quality. The Dietary Manager will ensure hot carts are plugged in during meal service to maintain proper food temperatures. Cold items will be kept on ice during tray line assembly to ensure they are served at a safe, appetizing temperature. The Dietary Manager/designee will complete 5 random food tray temperature audit 3 x per week for 30 days, 3 random food tray temperature audits 2 x week x 30 days, 2 random food trays temperature 1 x week for 30 days to ensure food is served at safe and palatable temperature. Randomized food tray temperature audit will be documented via paper documentation. The Dietary Manager will conduct an audit of the hot cart 3 x weekly at random meals times x 30 days, 2 x weekly x 30 days, once weekly x 30 day to ensure hot carts are being used properly during meal service. Hot cart audit documentation will be documented via paper documentation. The Administrator will review audit findings for trends or issues identified and report results to the Quality Assurance Improvement Committee monthly x 90 or until compliance is achieved.
0812Food Procurement,Store/Prepare/Serve-SanitaryS/S E▼
Findings
Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure safe and appropriate storage of food items in the pantry; and,-Ensure hand hygiene was conducted appropriately. Findings include:I. Failure to store food items appropriately in the the dry storage area A. Professional referenceAccording to the United States Department of Agriculture (USDA) Is Food In Dented Cans Dangerous? (9/18/24) was retrieved on 10/22/24 from https://ask.usda.gov/s/article/Is-food-in-damaged-cans-dangerous, food from cans that were leaking, bulging, or badly dented should never be eaten. The damaged cans could contain clostridium botulinum (a toxic bacteria)." B. Facility policy and procedureThe Food and Nutrition Services Staff policy, undated, was provided by the dietary manager (DM) on 10/17/24 at 6:21 p.m. The policy read in pertinent part, "The food service department is staffed by food and nutrition service personnel who have demonstrated the skills and competency to carry out functions of the department. "Food and nutrition service staff under the supervision of the dietitian and or the food and nutrition service manager, will safely and effectively carry out all functions of the food and nutrition services department." C. ObservationsOn 10/14/24 at 10:50 a.m. a can of garbanzo beans, a can of jalapeno peppers and two cans of tropical fruit were stocked on the first row and second rows of the can goods rack in the kitchen dry storage room. Each of the four cans of food had a dent on the side of the can. On 10/16/24 at 4:10 p.m. the dented can of jalapeno peppers remained on the shelf ready for use. The DM removed the can from the supply stock after she observed it. II. Failure to perform hand hygiene properlyA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/22/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment."If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation."The Center for Disease Control and Prevention (CDC) About Hand Hygiene For Patients in Healthcare Settings (2/27/24), retrieved on 10/22/24 from https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html, read in pertinent part, "Patients in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics, and protects healthcare personnel and patients." According to the CDC, hand washing should occur before preparing or eating food, before touching the eyes, nose or mouth, and after touching potential contaminated surfaces. B. ObservationsDuring a continuous observation of the dinner meal service in the main kitchen on 10/16/24, beginning at 3:55 p.m and ending at 5:22 p.m., the following was observed: At 4:00 p.m. cook (CK) #1 performed hand hygiene, donned (put on) gloves and scooped chocolate pudding into dessert bowls. He wrapped the dessert bowls in plastic wrap to cover the top of the bowl. CK #1 removed his gloves and touched the back of his pants with his left hand, adjusted his face mask by touching the front surface of the mask, retrieved a marker, placed his left hand over each cover bowl to hold the plastic wrap tight as he dated each bowl with the marker in his right hand. -CK #1 did not perform hand hygiene after removing his gloves and prior to touching the pudding bowls. Between 4:36 p.m. and 5:05 p.m. CK #1 touched his face multiple times while preparing the meals. Without performing hand hygiene while he plated ready-to-eat resident meals of hamburgers, burritos and vegetable pot pie. At 4:52 p.m. CK #1 left the service line with gloved hands and opened and closed the walk-in refrigerator. With the same gloved hands he retrieved a block of plastic wrapped pre-sliced cheese. CK #1 unwrapped the cheese and removed a slice with the same gloved hands and placed the slice of cheese on a hamburger patty for a resident meal. CK #1 did not perform hand hygiene or change his gloves before he touched the slice of cheese. At approximately 5:00 p.m., CK #1 removed two tortillas from a bag. He placed one tortilla on the grill. CK #1 held the second tortilla in his hand as the tortilla touched the front surface of his apron before placing it on the grill. At 5:12 p.m. CK #1 used the index finger of his gloved left hand to push his glasses closer to his face, without performing hand hygiene, he continued to plate meals.. III. Staff interviewsCK #1 was interviewed on 10/16/24 at 4:05 p.m. CK #1 said all the cans of food in storage should be free from dents and punctures because of the risk of potential food poisoning. CK #1 was interviewed on 10/16/24 at 5:35 p.m. CK #1 said the garden salad was kept on ice until it was placed to make sure it was served at a safe and palatable temperature. He said the salad had cheese on it and he did not want the salad to have a chance to grow bacteria if it was not kept at or below 41 degrees F. He said the garden salad should have been kept cold. He said he hoped staff would not set the hot box food cart on the highest setting or plug in the hot box so the salad temperature would not rise too high while in the hot box with warm food. CK #1 said hand hygiene should be done every time he touched surfaces that were not food related. He said he should not open the refrigerator door and then touch food without hand hygiene. The registered dietitian (RD) was interviewed on 10/17/24 at 12:26 p.m. The RD said she had not provided education for the dietary staff or kitchen oversight in the two months she had been at the facility but would welcome the opportunity. The DM was interviewed 10/17/24 at 5:21 p.m. The DM said CK #1 needed to have something put in place so his glasses so he would not continue to adjust them during meal service with his gloved hands. The DM said hand hygiene should be conducted every time a potentially contaminated surface touched gloved hands during meal preparation and service. She said she would review the facility ' s hand hygiene protocol with CK #1. She said food she not touch potentially contaminated surfaces such as CK #1 apron. The DM said she was the one who would usually put away food cans on the supply shelf and make sure there were no dents on the cans. She said for a short time she was not available to put away the cans on the shelf so the other dietary staff placed the food cans on the shelf after the cans were delivered to the facility. The DM said she had not provided education to staff not to put away cans with dents on the shelf because she was usually the one who did it. She said she would create an education, informing the dietary staff of risk of food borne illnesses to the residents from dented cans. She said dents in the can could break the seal of the can causing potential contamination of the food inside the can. The DM said she would establish a routine check of the food can stock.
Plan of correction · submitted by the facility
On 11/6/24, facility dietary staff were in-serviced on hand hygiene practices during meal preparation and service to ensure compliance with facility standards and resident safety. This training emphasized proper techniques and timing for hand hygiene to minimize contamination risks. In-service education was provided by the Dietary Manager for all dietary staff on the proper storage and handling of canned goods, with specific guidance on avoiding storage of dented or damaged cans. This in-service was completed on 10/24/24. On 10/21/2024, an audit of all canned food in the storage area was completed by the Dietary Manager. Dented or damaged food items were identified and immediately discarded according to facility policy and regulatory standards to prevent potential health hazards. The Dietary Manager will conduct audits of all canned food items in the storage area 3 x weekly for 30 days, bi-weekly x 30 days and then once weekly for 30 days. Each audit will be documented, and findings will be recorded to ensure consistent compliance with storage standards. The Dietary Manager/Designee will conduct hand hygiene compliance 3 x weekly of randomly selected dietary staff members, then 2 x week x 60 days. Observations will be documented, and findings will be recorded to track compliance with hand hygiene practices. The Administrator will review the documented audit findings for patterns or trends and report the results to the Quality Assurance Performance Improvement Committee monthly x 90 days or until compliance is achieved.
0880Infection Prevention & ControlS/S E▼
Findings
Based on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible developement and transmission of infectious diseases. Specifically, the facility failed to offer COVID-19 vaccinations and provide COVID-19 vaccination information to Resident #28, Resident #12, Resident #5 and Resident #17. Findings include:I. Facility policy and procedureThe Coronavirus Disease (COVID-19) - Vaccination of Residents policy, revised May 2023, was provided by corporate consultant (CC) #1 on 10/17/24 at 3:41 p.m. It documented in pertinent part,"Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so."The resident or resident representative has the opportunity to accept or refuse a COVID-19 vaccine, and to change his/her decision."COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his or her designee."Residents are screened for contraindications to the vaccine, medical precautions, and proper vaccination before being offered the vaccine."II. Record reviewA review of Resident #28's electronic medical record (EMR) revealed no documentation indicating the resident was not eligible for a COVID-19 vaccination. A review of Resident #28's mEMR revealed no documentation that the resident was offered the COVID-19 vaccination or that COVID-19 vaccination education was provided to the resident. A review of Resident #12's EMR did not reveal documentation indicating the resident was not eligible for a COVID-19 vaccination. A review of Resident #12's EMR revealed no documentation that the resident was offered the COVID-19 vaccination or that COVID-19 vaccination education was provided to the resident. A review of Resident #5's EMR did not reveal documentation indicating the resident was not eligible for a COVID-19 vaccination. A review of Resident #5's EMR revealed no documentation indicating the resident was offered the COVID-19 vaccination or that COVID-19 vaccination education was provided to the resident. A review of Resident #17's EMR did not reveal documentation indicating the resident was not eligible for a COVID-19 vaccination. A review of Resident #17's EMR revealed no documentation indicating the resident was offered the COVID-19 vaccination or that COVID-19 vaccination education was provided to the resident. III. Staff interviewsThe director of nursing (DON) was interviewed on 10/17/24 at 11:39 a.m. The DON said that there was no documentation indicating the COVID-19 vaccinations was offered to Resident #28, Resident #12, Resident #5 and Resident #17. The DON said the facility had not offered Resident #28, Resident #12, Resident #5 and Resident #17 the COVID-19 vaccination or COVID-19 vaccination education in the last calendar year. The infection preventionist (IP) was interviewed on 10/17/24 at 2:13 p.m. The IP said she had been in the IP role for two months. The IP said she was not involved in managing vaccinations in the facility and resident vaccination tracking was being completed by the DON. The IP said she did not know if any COVID-19 vaccinations had been offered to residents in the facility. The IP said it was important to provide vaccine education to residents so they could understand the side effects and benefits of that medical decision. The DON was interviewed again on 10/17/24 at 4:11 p.m. The DON said she had identified that the facility needed to do more to offer vaccines to residents in the facility and had begun the process of discussing flu and pneumonia vaccines with residents. The DON said the facility had not initiated a performance improvement plan regarding offering residents COVID-19 vaccinations. The DON said she was not aware of medical contraindications to the COVID-19 vaccine for Resident #28, Resident #12, Resident #5 or Resident #17.
Plan of correction · submitted by the facility
Resident # 28, Resident # 12, Resident #5, and Resident # 17 have been educated on COVID-19 vaccination, consents were obtained, and the Covid-19 vaccination were administered without adverse effects noted. All residents have the potential to be affected by alleged deficient practice. All residents residing in the facility were educated on the COVID-19 vaccination and consents or declinations were signed for the COVID-19 vaccination. All residents who consented were administered the COVID-19 vaccination. The facility will continue to offer the COVID-19 vaccination education on day of admission and will obtain consent or declination of the COVID-19 vaccine. All newly admitting residents who consent will receive the COVID-19 vaccination. Director of Nursing/designee will review new admission consent/declination forms and ensure COVID-19 vaccination was administered. Vaccination status will be documented and tracked via paper documentation. Process will be ongoing to ensure all residents are educated and have the opportunity to receive the COVID-19 vaccine. COVID-19 vaccination status will be tracked within Point Click Care and will be monitored monthly in Quality Assurance Performance Improvement committee to ensure all qualifying residents who desire COVID-19 vaccine have received the vaccination. The Director of Nursing/designee will complete a report on COVID-19 vaccination compliance and review monthly at Quality Assurance Performance Improvement committee x 90 or until compliance is achieved.
9/30/2024Revisit: Licensure Complaint Survey · ID KD7T12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 09/30/24 for all previous deficiencies cited on 7/31/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
9/30/2024Revisit: Complaint Survey · ID QXO312No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A revisit survey was completed on 9/30/24 for all previous deficiencies cited on 7/31/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
7/31/2024Licensure Complaint Survey · ID KD7T111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A survey prompted by complaint #CO37137 was completed on 7/30/24 to 7/31/24. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0703Res Care - Pressure Ulcer Prevention and Care▼
Findings
This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.
Plan of correction · submitted by the facility
Correction: Resident #1's wounds have made notable improvement with current treatment orders carried out by the comprehensive care provided by our facility. The resident's wound to right heel has dramatically reduced in size, wound bed is being covered with epithelial tissue which is part of the healing process. The areas to her sacrum, coccyx, and right foot plantar surface are completely resolved. The area to her right tuberosity has only one area that is open with thin layer of slough covering the wound bed without erythema present and reduction in size is noted. Resident #1 has been seen by infectious disease physician, Primary Care Provider (PCP) and Physician Assistant (PA) and all note wounds are healing without complications with current wound care and interventions implemented to heal her wounds. The facility is pleased to report that the wounds are healing or have healed, as evidenced by continuous monitoring and assessments. The resident's wounds have been under diligent care, and she is currently being treated by the Infectious disease physician and her Primary Care Provider (PCP) to ensure optimal healing outcomes. The Interdisciplinary Team (IDT) has actively reviewed and updated the resident's care plan, incorporating all necessary interventions to address the wound care needs as ordered. These updates were completed by the compliance date 8/24/24, ensuring adherence to all required standards and providing the resident with the highest level of care. Resident #1 care planned interventions: Daily wound care as ordered, air mattress and check functioning and placement every shift, increased protein at meals, frequent turning and repositioning throughout each shift, Registered Dietician (RD) consult completed and resident refused supplement (Prostat, Arginaid Powder, Boost,etc) to increase protein in diet, weekly labs as ordered, daily IV antibiotics, catheter care as ordered, Podus boot to right heel, pillows for comfort and positioning, float heels on pillows to offload pressure. Identification: A comprehensive audit identified residents at high, moderate, and at-risk levels, leading to the immediate implementation of preventive interventions and updates to individual care plans. A full head-to-toe evaluation of all residents was conducted and documented during the week of 8/8/24. Any abnormal findings prompted the completion of SBARs, inclusion in at-risk reviews, comprehensive skin pressure/non-pressure evaluations, prompt notification of the Primary Care Provider (PCP), and scheduling of necessary appointments for wound review and to obtain wound care orders. Systemic: Systemic changes implemented to ensure the deficient practice does not recur include comprehensive training by a CDPHE-approved wound care consultant for all direct care staff on wound prevention and care, following CDPHE guidelines. All nursing staff were re-educated on accurately completing the Braden Scale evaluations to identify residents at risk for skin breakdown. Additionally, all nursing staff were educated on the facility skin management policy. To enhance the ongoing management of resident care, further steps have been implemented to maintain and improve skin integrity among residents: Nursing Management Responsibilities: Assess the skin of all new admissions within 24 hours to ensure early detection and intervention. Review discharge paperwork within 24 hours of entry to confirm accuracy and conduct independent assessments to ensure proper skin checks are initiated upon readmission. Review head-to-toe skin assessments for all weekend admissions to ensure consistent care standards. MDS Staff Actions: Correct any non-triggering assessments on readmission to ensure comprehensive evaluations are completed. Interdisciplinary Team (IDT) Involvement: Review residents identified as high risk for skin breakdown to determine appropriate preventive measures and interventions. Discuss potential referrals to wound clinics for residents who may benefit from specialized wound care. Education Enhancements: Reinforce training for nursing staff on reporting requirements, high-risk Braden scores, and the prevention of pressure injuries. Conduct regular meetings between Nursing Management and nursing staff to address any immediate concerns or changes in residents' conditions. The Interdisciplinary Team (IDT) reviews the 24-hour report, Monday through Friday, utilizing the Morning Clinical Meeting Tool. This includes identifying any residents with newly developed pressure areas or any admissions with pressure areas. The Interdisciplinary Team (IDT) then reviews the situation surrounding its development to identify root cause and to ensure that appropriate interventions are in place to mitigate the source, and enhance the likelihood of the area resolving. The Director of Nursing, (DON) oversees this process. Monitoring: Documentation and Follow-up: Director of Nursing/Designee will perform weekly checks to ensure all skin assessment documentation is complete x90 days and will review at Quality Assurance Performance Improvement meeting. The Director of Nursing will ensure that Nursing Management receives re-education on the facility's skin management system to maintain high standards of care, as needed. Results of the weekly checks performed by the Director of Nursing/Designee will be discussed in the monthly Quality Assurance Performance Improvement Committee meeting x3 months to ensure that compliance is maintained in accordance with the facility policy. The Director of Nursing/Designee is documenting all of the information on new skin areas, as well as current pressure ulcers on the Weekly Pressure Ulcer Sheet in the evaluation section of the Residents medical record weekly and ongoing indefinitely. Director of Nursing/designee will submit a monthly report to the Quality Assurance Performance Improvement Committee on the Residents with current pressure ulcers and status of their wounds to ensure that compliance is being maintained with this facility policy monthly x90 days. Director of Nursing/Designee will monitor head to toe evaluations on five random residents 3x week x 30 days. Director of Nursing/Designee will monitor head to toe evaluations on five random residents 2x week x 30 days. Director of Nursing/Designee will monitor head to toe evaluations on five random residents 1x week x 30 days to ensure no unidentified pressure injuries exist for a total of 90 days and will be reviewed at monthly Quality Assurance Performance Improvement meeting.
Reportable Occurrences
37 records5/3/2026Neglect · ID 26020889010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/3/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a neglect event. An interested party involved in client (A)'s care notified the facility to report several concerns about staff (1). Reportedly, staff (1) declined to assist client (A) with personal care a few times, and with another instance, staff (1) allegedly left client (A)'s call light out of reach. The final concern was about staff (1)'s work ethic and staff (1) not responding to client (A)'s call light in a timely manner. During the course of the investigation, the healthcare entity checked on client (A) and another staff assisted client (A) with their care needs. Management suspended staff (1) and conducted assessments and interviews. Although no harm was identified, there was potential for significant harm. Due to staff (1)'s lack of professionalism and actions, management terminated staff (1)'s employment and notified staff (1)'s oversight licensing board. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/31/2026 · released to the public 8/7/2026.
4/14/2026Physical Abuse · ID 26020889007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/14/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (A) alleged staff (1) punched them in the chest while providing personal care. Client (A) could not recall the specific details about when the alleged incident occurred. During the course of the investigation, the healthcare entity suspended staff (1), notified the police and conducted an assessment and interviews. No visible injury was identified. Staff said client (A) becomes combative and thrashes aggressively while they attempt to provide care. Typically, two staff members assist the client and occasionally a third person is needed to help brace client (A), so the other staff can change client (A) and change the bed linen. Staff (1) denied punching the client but stated again that sometime staff "brace" the client, as described by providing supportive stabilization of the resident's arms, shoulders and legs while talking calmly through each step of care, so care can be provided. No clients or staff said they have witnessed staff (1) being physically aggressive. Review of work schedules revealed an agency staff member (staff 2) recently worked with client (A) and had similar characteristics to staff (1). Staff said staff (2) appeared to struggle with their work assignment and management placed them on a do not return list. No additional changes were made to client (A)'s plan of care, and staff (1) returned to work. Client (A)'s allegation could not be corroborated, and the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/23/2026 · released to the public 7/30/2026.
4/2/2026Verbal Abuse · ID 26020889006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/2/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a verbal abuse event. Reportedly, client (B) called client (A) several foul names, and then allegedly threatened to hit them. Client (A) reported feeling threatened and unsafe. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews, notified the police and implemented a monitoring plan for peer safety. Management moved client (B) to a new room, and staff requested a medical and medication review due to recent changes in personality and actions. Client (B) was diagnosed with a urinary tract infection, and antibiotics were started. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/10/2026 · released to the public 6/17/2026.
2/13/2026Verbal Abuse · ID 26020889008Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On x/x/xx, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported (occurrence type). During the course of the investigation, the healthcare entity (investigation steps). The event was/was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was/was not submitted within the required timeframe.
Publication
Sent to facility 7/27/2026 · released to the public 8/6/2026.
2/7/2026Neglect · ID 26020889004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/10/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a neglect event. Reportedly, staff (1) ignored client (A)'s request for assistance to fill the oxygen tank. During the course of the investigation, the healthcare entity suspended staff (1) and conducted an assessment and interviews. Client (A) and a second client corroborated the incident happened. Management terminated staff (1)'s employment. Although no harm was identified, there was potential for significant harm. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 5/13/2026 · released to the public 5/20/2026.
2/7/2026Neglect · ID 26020889003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/10/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a neglect event. Reportedly, staff (1) ignored client (A)'s request for assistance, purposely did not fill client (A)'s water and spoke to her unprofessionally. During the course of the investigation, the healthcare entity suspended staff (1) and conducted an assessment and interviews. Client (A) and a second client corroborated the incident happened. Management terminated staff (1)'s employment. Although no harm was identified, there was potential for significant harm. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 5/14/2026 · released to the public 5/22/2026.
12/8/2025Neglect · ID 25020889007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/10/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a neglect event. On 12/5/25, client (A) was transferred to the hospital for an evaluation due to a decline in her mentation and mobility. A hospital representative contacted the facility to report client (A) did not want to return to the facility. Client (A) told hospital staff she had not received good care at the nursing facility and felt unsafe. Client (A) reported instances of being handled roughly by staff when they provide care, concern about her functional decline, not receiving prescribed medications consistently or properly, feeling bullied by staff, fear of retaliation and feeling dehumanized by the way staff treated her (refer to case # 25020889008 for further details regarding alleged abuse). During the course of the investigation, the healthcare entity conducted interviews, record reviews and checked on current clients to ensure their needs were being met. Client (A) did not return. No current clients have reported these types of concerns with staff or their care. Findings showed the client’s mobility declined and there were frequent refusals to participate in therapy services. However, services were offered. The facility acknowledged the client reported feeling uncomfortable during some care interactions and recognized the importance of professionalism, respectful communication, and client dignity. Through the facility’s findings, care and services were offered per physician orders and care plans. There was no identification of untimely medication administration. The facility took the opportunity to provide re-training to staff on abuse, medication management, incontinence care, customer service and providing proper care. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/10/2026 · released to the public 3/17/2026.
12/8/2025Physical Abuse · ID 25020889008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/10/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. A hospital representative contacted the facility to report client (A) did not want to return to the facility. Client (A) reported she had not received good care (refer to neglect case ID#25020889007 for further details) and felt unsafe. Client (A) reported instances of being handled roughly by staff when they provided care and reported feeling bullied by staff, fear of retaliation and feeling dehumanized by the way staff treated her. During the course of the investigation, the healthcare entity notified the police and conducted interviews and record reviews. Client (A) did not return. Review of skin records identified areas of redness, bruising and a blister. Most skin integrity areas were attributed to clinical factors. One bruise appeared to be consistent with the application and pressure from an incontinent brief being on too tight. At the time, the bruise was not considered to be a result of mishandling. The facility acknowledged client (A)’s reported concerns regarding care interactions and recognized the importance of their perception, comfort, and dignity during personal care. No other clients reported having concerns like client (A). Re-training occurred on topics of abuse and for staff to provide safe and gentle incontinence care practices with emphasis on professionalism and dignity. Client (A)’s allegations could not be corroborated, and the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/10/2026 · released to the public 3/17/2026.
7/7/2025Diverted Drugs · ID 25020889006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/9/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a diverted drug event. Reportedly, client (B) alleged she had not received her pain medications when requested. Floor staff reported agency nurse (1) was observed to be sleeping and unresponsive to the clients’ requests. Concerns were expressed that nurse (1) appeared impaired while working. When management showed up, nurse (1) left the building promptly. Nurse (1) left the medication cart keys unsecured and did not conduct a medication count or client handoff to another licensed professional. Following nurse (1)'s departure, nurse managers conducted a substance medication count that revealed discrepancies for three clients and there was concern regarding a potential drug diversion. During the course of the investigation, the healthcare entity terminated nurse (1)’s work contract, conducted medication audits and counts, assessments and interviews. Client (B) received her pain medications and reported relief. The facility concluded nurse (1) engaged in unprofessional standards of practice, facility policies and licensure expectations. Due to the findings, there was a high suspicion of a drug diversion and the event was substantiated. Nurse (1) was reported to the oversight licensing boards. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 10/9/2025 · released to the public 10/16/2025.
5/29/2025Physical Abuse · ID 25020889005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/30/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, staff observed a new skin tear on client (B)’s arm. Client (B) alleged staff (1) hit her causing a skin tear. During the course of the investigation, the healthcare entity removed staff (1) from the work schedule, conducted an assessment and interviews, implemented care in pairs and notified the police. First aid treatment was provided. Interviews indicated client (B) had been agitated and staff observed her flailing her arms when in bed and near her nightstand. Staff said client (B) also said the skin tear was attributed to a self-injury when she became frustrated with her remote control. The abuse event could not be substantiated. Client (B)’s care needs were reassessed to help provide ease with the television and staff continued supporting and meeting her needs per her individualized plan of care. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 9/4/2025 · released to the public 9/11/2025.